The importance of keeping an after-hours call log

Keeping a record of calls you receive out of hours from other clinicians is crucial for patient safety and risk management. Poor communication can negatively impact the quality of patient care and can result in administrative mistakes and even serious triage scenarios. If you are subject to a claim or complaint, your notes will be your best defence.

In this article, we’ll recount two real-life examples of when doctors’ medical records have influenced the outcome of a legal dispute, for better or worse, and provide tips for effectively logging after-hours calls.

If calls between clinicians regarding a patient’s care are not properly documented, it could risk the patient’s safety and could leave the doctor vulnerable if a complaint is made. This is what happened to a doctor we spoke with in our It happened to me podcast series, where he shared his experience of being involved in a disciplinary process but was saved by his notes.

The case

At the time of the event, Dr S was an anaesthetist who stepped in as an emergency cover for a colleague in the post operative period but was given an inaccurate handover.  Unfortunately, the procedure had an adverse outcome for the patient, which Dr S only found out eight days later.

The hospital began an investigation into the procedure, and Dr S was advised by a mentor to write down exactly what happened (who he spoke to and what they spoke about) and sign and date the notes.  As a result, he had contemporaneous notes, unlike his colleague who had to rely on guesswork 12 months later. Dr S’s notes saved him from disciplinary action, but his colleague was disciplined for his failure to document.

A lesson in record-keeping

The court case took four years to resolve, and Dr S’s records were key to his successful defence, but the whole ordeal caused him great stress.

Now he tells his colleagues and registrars to be vigilant about documenting everything that happens – even when they have checked in with a patient but not changed their care at all. The experience has made him more aware of the importance of documenting informal conversations and after-hours calls.

He has developed a method of logging calls he receives out of hours. In the podcast, Dr S says:

“I have a log that sits on my desk at home. I no longer answer phone calls at home in bed. I get out of bed, go to my study and turn the light on. I tell whoever it is, ‘Stop, hang on, wait for it,’ and the only time I won’t do that is if I say, ‘Do you want me now?’ and they say, ‘Yes’ and I’ll hang up and I’ll bolt. But if I’m at home, I write it, date it, sign it.”

This note-taking method ensures all communication between clinicians and carers about a patient’s care is documented and tracked and can be referred to during the handover of care. The process may vary but ideally have a system in place to ensure you capture all the necessary information.

While Dr S had good records that supported him in a legal dispute, poor record-keeping was the downfall of Dr N in a disciplinary tribunal case.

In this real-life case, Dr N operated on a child patient but failed to provide adequate follow-up care. The evening after the operation, the child’s parents reached out to the doctor with concerns about the child’s worsening condition but were told there was nothing to worry about.

The parents eventually sought a second opinion from another GP who advised them to take the child to the hospital immediately, where he underwent a further operation.

Dr N’s versions of events did not match that of the parents, and as he did not have contemporaneous notes to support his claims, the tribunal concluded that his care fell below the required standard.

The outcome of the tribunal

The tribunal found that Dr N had failed to obtain informed consent from the parents and did not make them aware of the complication risks. It was also concluded that Dr N failed to record notes about the patient that were important for other clinicians to know, thereby posing a serious risk to the patient.

Following the tribunal’s outcome, Dr N was required to report monthly to the regulator on all procedures undertaken, including details of the clinical notes, informed consent and follow-up care provided.

This cautionary tale highlights the importance of having a system in place to create accurate, contemporaneous notes regarding patient care including all discussions that occur, any information shared (e.g. photographs or diagrams) and when consent was obtained.

Read more about the case: GP’s follow-up care and record-keeping found to pose a serious risk of harm

When documenting after-hours calls, ensure your notes are clear and include details such as the reason for the call, key clinical findings, actions taken and recommended follow-up care.

Key points to include in your after-hours call documentation:

• Patient information: Full name, date of birth, contact details, referring physician (if applicable).
• Time and date of call: Precise time the call was received.
• Reason for call: Clearly state the patient’s presenting complaint or concern, including any relevant symptoms.
• Clinical assessment: Briefly summarise key information gathered during the call, including pertinent medical history, current medications, and any relevant findings.
• Management plan: Detail any advice given, including instructions for further monitoring, medication adjustments, or immediate actions to take.
• Follow-up plan: Specify when and how you expect to follow up with the patient, whether by phone call, in-person appointment, or further testing.
• Urgency assessment: Clearly state whether the call was considered urgent and why, including justification for not referring to emergency services if appropriate.
• Communication with other healthcare providers: If you contacted another healthcare professional regarding the patient’s care, document the details of that communication.

Important considerations when documenting calls:

• Avoid unnecessary jargon and write in a clear, concise manner.
• Double-check all information for accuracy, including patient details and medical history.
• Maintain a professional tone throughout your documentation, noting that the patient may read the notes as it is their right to access them.
• Be mindful of potential legal implications when documenting sensitive information.
• Always adhere to your practice or hospital’s established documentation guidelines and policies for after-hours calls.

You may consider using a standardised template for consistency. A formula like ISOBAR can help to ensure there is strong communication between caregivers.

I – Identify

S – Situation

O – Observe

B – Background

A – Agree a Plan

R – Readback

Maintaining contemporaneous and accurate medical records is essential for the handover of patient care but can also help when something goes wrong. If you receive a call out of hours from another clinician regarding a patient’s care, make sure you document everything that was discussed on the call using the tips listed above and then transfer the notes to the patient’s record as soon as you can.

Doing so will ensure the patient receives the right care and will also be your defence if you subsequently find yourself involved in a legal dispute.

Factsheet: Medical record: the essentials

Claims insights: Medical records