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Pediatric practice is telephone intensive. This is consistent with the minor nature of most pediatric illnesses. Most calls to the pediatrician are for reassurance that the child is not seriously ill. More problematically, most calls are handled by office personnel other than the physician in charge. These calls are seldom recorded in the patient's chart, and calls are often answered without reference to the chart. This leads to the most common telephone-related legal problem: misunderstanding about the severity or progression of the child's illness.

One of the most important diagnostic indicators for children is the parent's level of concern. If a parent calls the physician's office repeatedly over a period of hours or days, this should alert the physician that the child should be seen immediately. Legally, it is very difficult to defend cases in which the parents have repeatedly called the physician's office. If the child is injured due to a missed diagnosis or treatment failure, the jury will assume that the problem could have been managed if the child had been seen.

Physicians must know what their office personnel tell patients who call with medical questions. There must also be a protocol to identify the cases that must be handled by the physician and potential emergencies. In addition to the general telephone problems discussed in Chapter 9, pediatric telephone advice poses special problems that are beyond the scope of this book.[212]

When the physician on call has not had an uninterrupted meal or night's sleep in a week, it is easy to forget that one cannot look at a rash, listen to a chest, or palpate an abdomen over the telephone. The mother's description is not a substitute for a physical examination. If the child potentially has any condition where proper care decisions would require a physical examination, the child should be sent to the office or the emergency room immediately. If the mother is unreliable, then her descriptions over the telephone are also suspect. If the mother is reliable, then she would not call late at night unless she has a serious concern.

The same basic information must be recorded for every telephone call: date; time; name and age of the patient; telephone number; symptoms; disposition of the call; whether it is a repeat call; and the person handling the call. In most offices, the only practical way to record this information is in a telephone log. It is too difficult to pull patient charts for every call. Using a central telephone log also allows the supervising physician to monitor the management of calls in the office. The problem with telephone logs is that they can prevent important medical information from being incorporated into the patient's chart.

There must be a protocol to determine what information should be transcribed from the telephone log into the patient's chart. This problem will be eased considerably if the physician uses a telephone log with a preprinted information form on 2-part carbonless paper. Ideally, the copy of every call slip will be filed into the patient's chart. If this is impossible, it is critical to transfer all treatment recommendations, prescriptions, refill call-ins, referrals to the emergency room, and repeat calls for the same problem.

[212]Schmitt BD: Pediatric Telephone Advice. 1980.

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