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How Can We Make Sure Discharge Phone Calls are JCAHO and HIPAA Compliant?


JCAHO now says discharge phone calls should be documented in the medical record. I am concerned that this will reduce the number of calls. Any ideas on how to keep JCAHO happy and not overburden nurses, so they will continue to make the calls? Also, what are the implications for HIPAA?


One method that works well is to create a form that’s kept on nursing units in duplicate. The form features a checklist followed by an area to summarize the call focusing on clinical issues. This form can even be the scripted outline of the call, which helps standardize how calls are made by staff. The unit coordinator collects the forms each day and sends them to the medical records department, where they are filed in patients’ charts. This method allows the manager to keep a copy for reward and recognition opportunities, process improvement ideas, and so forth.

Another method is to keep the chart on the floor for 24 hours and document calls directly on the chart before it is sent to medical records. If this is not possible, a stamped nurse’s note, one labeled with the patient’s name, can be retained on a clipboard. It can then be used for the call and sent to medical records.

For HIPAA, we do not see any concerns as long as you take a few steps. Many organizations ask the patient before discharge if they can call her at home as they want to check up with her. This may be documented on a checkbox or may trigger the creation of one of the documents above. You may also ask if you can leave a message. This is documented right on the call sheet that will be used later to call the patient. If a message is left, it should be a standard generic key phrase. Some organizations do not leave messages, but simply note that they made a call attempt on the documentation sheet. Studies—including the article documented below—have shown that up to 19 percent of patients will have some type of adverse reaction within 72 hours of discharge (“Adverse Events After Discharge from Hospital,” Feb. 2003 issue of Annals of Internal Medicine). Discharge phone calls are critical in improving the clinical outcomes of patients. Adjusting the process for discharge calls to make sure they are compliant with regulations is not difficult and should not be a barrier to hardwiring them.