Linda asked: <<How detailed do you all get when documenting phone
conversations? My boss is concerned that our log is too specific and
could be called into court as evidence if there are ever any issues.
She would like to see a more vague charting in the log or no log at all.
Are we not required to document advice given as a phone consult? If so,
how long are we required to keep those records? Do any of you document
triage calls electronically and, if so, how do you generate a chart on
an outside referral?>>
I don't know how helpful my reply will be since my setting is public
health (WIC), not a hospital. But for what it's worth, the bulk of our
work is phone work and we document every bit of it in detail. We used to
document on paper but years ago switched to electronic documentation.
(A computer program I learned about at a lactation conference...not sure
if it's okay to mention the name; I have no affiliation with them
whatsoever. It has its flaws but it's better than paper!)
Some background may help: the Miami-Dade County WIC program currently
has a monthly caseload of over 66,000. The breastfeeding caseload
(numbers of women monthly listed as doing any breastfeeding) is around
8000. There are 18 WIC sites spread around the county. Our
breastfeeding program serves them all. Towards this end, we have 5
full-time IBCLCs including myself and my boss and 9 other staff members
(some full-time and some part-time). Some are federally-funded PCs and
most are CLCs. The linchpin of the entire thing is our warmline.
All of that is a long-winded way of saying: we have a large caseload and
do a LOT of phone work. I can't imagine us NOT documenting them.
The thing I like best about our detailed electronic documentation is the
consistency of care provided to the client on an ongoing basis. Because
we have a track record of every phone call she's ever made to our
helpline, we have a through line - a storyline, if you will. Women will
call back repeatedly over the course of their nursing relationship/s
with questions great or small, and we always know who she last spoke to,
who her LC is, the content of each discussion any of us have had with
her and the entire history of her case.
And yes, we did have to go to court once and it was a good thing we were
keeping records as the situation started on the phone and our records
supported our contentions. So even legally I don't understand the
benefit of NOT keeping records. It seems riskier to me not to - it's not
like a lack of records will keep us out of court. But I'm no lawyer....
Regina M. Roig-Romero, BS IBCLC
Senior Lactation Consultant
Miami-Dade County Health Dept WIC/Nutrition
Breastfeeding Program
7785 NW 48 ST, Suite 300
Miami FL 33166
(786) 336-1333 x162
(786) 336-1345 fax
(786) 336-1336 Breastfeeding Helpline
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