■ Physician-patient:

Communicating effectively with patients to optimize their care

Documentation of telephone advice

Type of activity: Quick activity

Activity summary

These 3 short scenarios illustrate situations in which physicians are required to document telephone discussions. The facilitation questions focus on helping learners to identify the key information that should be documented.

Scenarios

Scenario 1

As a medical student, you have contacted your resident regarding a ward patient with a fever. The resident orders some acetaminophen (Tylenol) but says they will assess the patient in the morning.

How would you document this phone call?

Scenario 2

As a medical student, you contact the attending physician regarding a patient with chest pain. They ask you to get a cardiology consult and order an ECG, chest X-ray, and serum cardiac markers.

How would you document this advice?

Scenario 3

A patient who is 1 week post-op from abdominal surgery contacts you regarding their swollen leg. You ask the patient to go directly to the emergency department, and you contact the emergency physician to let them know the patient will be coming.

How would you document this call and your advice to the patient?

Additional resources

CanMEDS: Collaborator, Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.