Telephone Order Documentation and Authentication

General Principles

• The American Academy of Pediatrics recommends that documentation should include date and time of call, patient identification, caller name, reason for call, total encounter time, relevant history and evaluation, assessment, plan, and disposition 1, 2, 3, 4, 5, 6
• All telephone encounters should be placed in the medical record to ensure continuity of care and demonstrate complexity of decision-making 1, 2, 3, 4, 5, 6

Documentation and Billing

• Telephone care billing and reimbursement guidelines are available 1, 2, 3, 4, 5, 6
• General documentation principles for medical records are established 7

Electronic Communication

• Electronic mail communication guidelines are available 8, 9

Documentation and Workflow for Telephone Encounters

Importance of Documenting Telephone Communications

• Verbal telephone messages are frequently overlooked, forgotten, or lost; therefore, documenting the encounter creates a permanent record that supports continuity of care and legal accountability. Evidence level not specified. 10

Standardized Templates to Improve Documentation Compliance

• Implementing a standardized documentation template within the electronic health record ensures consistent capture of all required elements (date/time, patient ID, provider ID, reason for call, history, assessment, plan, disposition, and encounter duration), which enhances compliance with documentation standards and streamlines the workflow for telephone encounters. Evidence level not specified. 11