(1) In general telephone advice should only be given to a patient who has been previously registered with a practice, clinic or hospital.
(1a) A registered patient will have a medical record with medical history, baseline examination and current contact information.
(1b) An unregistered patient should be directed to an emergency room, urgent care center or primary care provider so that a proper evaluation with physical examination can be performed.
(2) The telephone session should follow the regular care process, with a documentation of the complaint, history, presumptive diagnosis, advice and followup plan. Current contact information should be confirmed or collected.
(3) The patient's chart should be at hand if possible. The details of the telephone session should be recorded immediately if possible, but no later than the end of the day.
(4) If the chart is not available or the provider is away from the office:
(4a) The provider should perform a more complete review of the medical history, medications, allergies and other pertinent factors.
(4b) A note of the telephone consultation should be recorded immediately. This should be added to the chart once located or upon return to the office.
(4c) The chart should be reviewed and the patient contacted if any significant change in the advice or followup plan is required.
(5) The patient should be informed that a telephone evaluation has significant drawbacks compared to a face-to-face evaluation.
(6) An appointment should be made for follow-up evaluation of the patient. Patients with complaints that could indicate severe disease should be physically evaluated immediately.
