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  • 1.  Documenting information from a caller other than the patient

    Posted 11-15-2022 08:51
    A question came up recently about documenting information from a source (not the patient). 

    For example: 

    Husband calling to report his wife is "not doing well". 
    Boyfriend calling with concerns his girlfriend is diverting the medication we are prescribing. 
    Mother calling for 19 year old son to report he had chest pain after practice last night. 

    Is taking information from a 3rd party a privacy violation? Is it hearsay and should be disregarded? 

    Thanks for your thoughts.

    ------------------------------
    Susanna Gadsby MSN, MBA, AMB-BC, NPD-BC
    Clinical Educator, Ambulatory
    AAACN Certified
    Nursing Professional Development Specialist
    susanna.m.gadsby@hitchcock.org
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  • 2.  RE: Documenting information from a caller other than the patient

    Posted 11-16-2022 12:55

    When a person calls on behalf of someone else, we do not triage unless that someone else is present and can give permission for us to speak to the person calling. If that someone else is not present, we encourage the caller to call back when they are or have that person call for themselves. Of course, there are exceptions if the caller is the main caregiver, guardian, etc.; however, even then we insist the person is present as there are so many questions that only the affected person can answer.

     

    Catherine Bailey, BSN, RN                         

    Assistant Clinical Manager-Telephone Triage/Telecommunications

    Providence Health & Services Alaska

    907-212-6493       

    907-212-3959 fax

    Logo, company name Description automatically generated

     



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  • 3.  RE: Documenting information from a caller other than the patient

    Posted 11-17-2022 08:15

    You are allowed to receive information and document as such. You are not allowed to give information.  There may be risk involved if someone calls with an urgent message and it is ignored because the person is not present.

     

    Susan

     

    Susan B. Sell, MSN, RN, AMB-BC

     

    Sr. Education and QI Specialist

    LVHN Integrated Care Coordination – Outpatient

    707 Hamilton St. 5th floor

    Allentown PA 18101

     

    Susan.sell@lvhn.org

    484-523-9487

     

     



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  • 4.  RE: Documenting information from a caller other than the patient

    Posted 11-18-2022 14:24

    We don't often get messages as we are a triage department; however, if we did we would try and help get that message to the right person. I would like to clarify that nothing is absolute. There are situations in which someone is incoherent or clearly not able to speak for themselves and may need immediate assistance. This is where our wonderful critical thinking skills come into play. We have to be careful because our process is to document everything in the EMR of the person needing triage.

     

    Catherine Bailey, BSN, RN                         

    Assistant Clinical Manager-Telephone Triage/Telecommunications

    Providence Health & Services Alaska

    907-212-6493       

    907-212-3959 fax

    Logo, company name Description automatically generated

     



    This message is intended for the sole use of the addressee, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the addressee you are hereby notified that you may not use, copy, disclose, or distribute to anyone the message or any information contained in the message. If you have received this message in error, please immediately advise the sender by reply email and delete this message.



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  • 5.  RE: Documenting information from a caller other than the patient

    Posted 11-17-2022 16:22
    Edited by Adina Steen 11-17-2022 16:23
    I agree with Susan. I was always taught that if someone other than the patient calls, you are allowed to receive information and you can ask general clarifying questions. But you cannot relay any information or discuss treatment/advice without the patient's permission - written is preferable, but verbal is ok. If verbal, it should be clearly documented that the patient has provided permission for us to discuss their care with this other person.

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    Adina Steen, RN, BSN, AMB-BC
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    Original Message


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