SCPA Posted November 1, 2015 Share Posted November 1, 2015 If you didn't write it down, it didn't happen--At least that's what they drilled in to our heads in school. I take call for our clinic and nursing home patients. The nursing home is not on an EMR. Many times orders are given over the phone to the nurse. I really have no way of documenting these calls aside from writing them down at home, then making a note in the chart next time I'm in the facility... Should I be doing this!? I know none of the other providers in my office document call phone calls and orders. What do you think? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 1, 2015 Administrator Share Posted November 1, 2015 Make the nursing home fax back a copy of what you told them to your office, where you can concur or correct it the following business day. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 1, 2015 Moderator Share Posted November 1, 2015 Make the nursing home fax back a copy of what you told them to your office, where you can concur or correct it the following business day. and keep these on file....I have to take phone call for an inpt psych facility at one of my jobs(don't ask, it's a terrible situation) and I have them read back my orders and send me a copy in the EMR for my signature. The questions they ask are ridiculous. they wanted an emergent evaluation the other night for a known dm pt with a CBG of 187. I swear, the worst nurses at our facility end up in psych... Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 2, 2015 Moderator Share Posted November 2, 2015 by the book - - - review them and verify them the next business day in reality - that might be next to overwhelming..... try to do your best to do read backs, offer education on the phone, and follow up on the ones that actually might be sick or needing looking in on. I was in a practice covering almost 1200 nursing home patients..... no way to handle those all ...... Link to comment Share on other sites More sharing options...
casias Posted November 3, 2015 Share Posted November 3, 2015 I don't get this very often from nursing homes, but I did recently. The NH took the telephone order from me, and faxed their written order the next day to be signed. Sounds like this isn't common practice? Link to comment Share on other sites More sharing options...
Febrifuge Posted November 5, 2015 Share Posted November 5, 2015 ... I know none of the other providers in my office document call phone calls and orders. What do you think? I think the other providers in your office are flirting with disaster, honestly. You're in the right here. "If it's not documented, it didn't happen" is also how the malpractice lawyers think about the issue. Link to comment Share on other sites More sharing options...
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