Phone call documentation

The Alberta Medical Association (AMA) would like to remind physicians to properly document telephone communication for all patient encounters, including related conversations with nursing staff, other physicians and health care providers that often are not recorded in the chart at a facility.

Alberta Health and Wellness’ Health Care Programs Compliance unit has advised that many physicians undergoing review have inadequate records.

Suggestions to help with this task are:

  • Purchase a small book where pages cannot be added and keep it and a pencil with you at all times. You can track and record phone calls with various providers. This will also serve as a log for billing purposes. The log should be kept and maintained in chronological order.
  • Every encounter with a patient should be recorded in the patient’s chart including visits billed on a cumulative time basis; this way all callbacks and multiple encounters on the same day can be recorded and reflected accurately in the chart in the event of an audit or billing review.
  • Not all phone calls are billable to AHW. Refer to the Schedule of Medical Benefits for a full list and their rules.

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.