8. Telephone Techniques

INTRODUCTION TO TELEPHONE TECHNIQUES

Contact with a patient takes many forms. In addition to face-to-face contact, medical assistants often speak to patients and other callers over the telephone. The telephone is often the first contact between the medical office and a patient. In addition, the telephone is used throughout the day to make and receive referrals, request laboratory results, call in prescriptions for patients, and respond to patient questions.

Managing the phone is one of the most important jobs in the office. It is the first chance the medical assistant has to project a positive attitude and image to a patient. One never has a second chance to make a first impression.

USING THE TELEPHONE EFFECTIVELY

Telephone Courtesy

The telephone in a medical office should always be answered promptly. Some offices have a policy that every phone call should be answered within three rings. The medical assis­tant identifies the office, gives his or her name, then finds out who is calling. If the call will be transferred, the staff member needs to know who will be on the other end of the call.

The medical assistant should always speak before putting someone on hold. It is not courteous to place a call to hold immediately before speaking to the caller. The caller cannot even be sure that they have reached the correct telephone number. It is far more polite to obtain the caller’s name and purpose for calling before putting the caller on hold. It is helpful to keep a written record of each caller’s name, with the number of the line where he or she is holding. A physi­cian should not be placed on hold if it can be avoided. The medical assistant should check back about every 30 seconds or so with a person who is on hold. This reassures the caller that the medical assistant is aware of the call. The medical assistant should also try to give an idea of how long it will take before the call will be answered.

When handling a call, the medical assistant should not chew gum or eat. Paying close attention during the tele­phone call is also important. A caller can tell if the medical assistant is distracted.

Telephone Personality

In addition to words, many nonverbal cues are given in the quality of a medical assistant’s voice on the telephone. The “telephone personality” is important. It is important to stay focused on the call and smile. The medical assistant should use the same volume as when speaking in person and speak naturally. An artificial telephone voice may be perceived as cold and “fake.”

All words should be spoken clearly so that they are easy to understand. Enunciation is the act of speaking so that the message can be easily understood. It may be necessary to speak a little more slowly on the telephone, and it is very important to avoid mumbling. It may be helpful for a medical assistant to record a telephone greeting and analyze the quality of his or her voice and the personality that is projected.

Qualities such as interest, friendliness, concern, and understanding are clearly communicated over the tele­phone. So too are boredom, anxiety, and indifference.

Effective Telephone Communication

When speaking on the telephone, the medical assistant should try to complete the call without interruption. If it is necessary to put someone on hold, the medical assistant should give a reason and apologize to the caller when the call is resumed. Information and materials should be readily available to handle calls and take messages. These include message slips, a pen, the office appointment book or com­puter appointment screen, and a list of frequently used telephone numbers. A desk clock, computer clock, or wrist- watch should be visible to note the time when taking messages.

The medical assistant begins the conversation by identi­fying the practice—for example, “Primary Care Associates, Channa speaking.” If the caller asks a question or asks for a staff member without identifying himself or herself, the medical assistant asks politely for the caller’s name: “With whom am I speaking?” or “May I ask who is calling?” Using complete sentences is important because the medical assis­tant does not want to sound abrupt or rude.

The medical assistant should sit with the back supported and the head in a neutral position (not forward or to one side). The feet should be flat on the floor or supported on a foot stool. Figure 39-1 shows proper body position for answering the telephone. If the receiver is tucked between the head and shoulder, it places strain on the shoulder muscles and may change the voice quality, so this should be avoided. A headset, which consists of an earpiece that fits over the ear and a mouthpiece in front of the mouth, allows for good body posture and leaves the hands free. This is

Figure 39-1 Good posture when answering the telephone improves voice quality and prevents muscle strain.

Figure 39-2 A telephone headset leaves the hands free and facilitates good body posture.

Recommended if the medical assistant spends a lot of time on the telephone. Figure 39-2 shows such a headset.

The medical assistant should be clear with callers who leave messages about when they can expect their calls to be returned. Many physicians have specific times when they return nonurgent telephone calls, such as late morning, lunch time, or the end of the day.

One should avoid cutting into a person’s replies, even if he or she rambles on and repeats information. When the medical assistant gets the chance to speak, he or she should try to give a focused answer that lets the caller know what can be done and what the medical assistant is going to do.

TELEPHONE TECHNOLOGY

Advances in telephone technology have given medical offices many options to maintain contact with patients, physicians, pharmacies, laboratories, and hospitals.

Multiline Phones

Most offices have a multiline phone, with several exten­sions. It is important for the medical assistant to learn how to determine which line is ringing, how to place calls on hold, and how to transfer calls to all parts of the medical office. Figure 39-3 illustrates a multiline telephone with many extensions.

A flashing light usually identifies a line that is ringing; it flashes at a different rate on a line where a person is on hold. The medical assistant answers a call by pressing the button on the telephone that corresponds to the line that is ringing. If a second call comes in while the medical assistant is speak­ing to a caller, the medical assistant should tell the first caller that he or she needs to place the caller on hold, then he or

Figure 39-3 A multiline telephone is commonly used in a medical office.

she presses the hold button. The medical assistant answers the second call, identifies the caller, and usually places that caller on hold before returning to the first caller and apolo­gizing for the interruption. The calls are then handled in order.

If the caller asks to be connected to another extension or person, the medical assistant should first obtain the caller’s name. To transfer a call, the medical assistant may need to press another button and/or dial an extension number, depending on the type of telephone system. Knowing the caller’s name allows the medical assistant to announce the caller when the call is connected, and it is also helpful if the call is disconnected for some reason.

While a caller is on hold, the light on that line will flash. If the light continues to flash, the medical assistant should pick up that line about every 30 seconds and ask if the person would like to continue holding or leave a message. Sometimes transfers do not go through or the call is not picked up.

Special Features

Multiline telephone systems come with many other fea­tures, including speed dialing, call forwarding, call park, and caller ID.

Speed dialing allows storage of frequently called tele­phone numbers in the telephone system’s memory. These numbers can be called by pressing a button or a one- or two-digit code.

Call forwarding allows forwarding of incoming calls to another telephone number. This service is turned on and off by dialing a sequence of numbers and activity keys.

Call park allows a call to be placed on hold and retrieved from another telephone.

Caller ID identifies the caller’s telephone number before the telephone is answered. This feature may be avail­able on some, but not all, telephones within a tele­phone system.

The medical assistant must learn how to use these and other features of the telephone system efficiently.

Answering Machines and Voicemail

Physicians have always needed to be available at all times. Most physicians’ offices still use an answering service for getting messages to physicians during hours when the office is normally closed. This is an independent company that answers telephones for a number of clients. Some offices also have an answering machine or voicemail system, which has a message with a number to call outside of office hours and gives people the option to leave a nonurgent message. Voicemail is a method for message delivery, storage, and retrieval that is built into the telephone system. It is usually attached to each individual extension. Answering services and answering machines are activated whenever the office is closed, including during lunch break if no one is assigned to take phone calls during that time. The answering service should be notified if the office is closed, although they usually pick up phones after a predetermined number of rings.

Increasingly, physicians’ offices are going to voicemail systems. Voicemail is a system provided by the office’s tele­phone carrier that allows for messages to be left in a number of “mailboxes” for different people. Each physician might have his or her own voicemail box, as well as each medical assistant, the business manager, and so on.

The message will have a number to call for urgent mes­sages outside of office hours but will also offer the caller the option of leaving a message in any voicemail box. Each box has a two- to four-number extension. Many voicemail systems have a directory by which people can find voicemail box numbers by using their touch-tone phone to type in some or all of the letters of the last name of the person with whom they would like to speak.

Even if an office has a voicemail system, most medical offices will still need to have a contract with an answering service. The answering service provides a medical office with coverage outside of normal business hours. The service either answers all of the office’s telephone calls or takes calls that are forwarded to it by individuals who listen to the voicemail system message and press the appropriate message code for an urgent message. The answering service must be informed how to deal with urgent calls.

Cell Phones and Smartphones

Cell phones allow two individuals to speak to each other as they would using regular telephones, but the cell phone uses radio signals instead of telephone wires. A smartphone is a device that adds computer capabilities to the cell phone, with a drug reference, address book, and other tools; an Internet connection; the ability to send and receive e-mails; and sometimes even access to the electronic medical record system used by the health care facility. This type of hand­held computer was formerly called a personal digital assis­tant (PDA), but today almost all PDAs are smartphones. Many physicians use cell phones or smartphones to remain in contact with the medical office when they are in other locations. The physicians’ cell phone numbers should never

Putting It All into Practice

My name is Channa Eng, and I am a certified medical assistant. I work for an internal medical practice with two physicians and two nurse practitioners in an urban area. We have many Asian and Hispanic patients. I don’t speak much Spanish, but I do speak Cambodian and some Vietnamese. Another medical assistant speaks Spanish, and we both help with translating telephone calls from patients who have difficulty in English. When patients call our office, they get three choices right away. They can hear the message in English, Spanish, or Cambodian. Most patients like this because they can hear the instructions in a language they are comfortable with. On Tuesdays and Thursdays, I spend most of the day on the tele­phone making appointments and responding to patients with medical problems. I don’t usually sit at the front desk. Instead, we have a telephone room with three telephones. When it is very busy, there are usually two of us. I can tell if a patient wants a routine appointment or has medical questions depending on which line the call comes in on. When patients are sick, I have to ask a lot of questions to find out how urgent their problem is. Last year I worked with the office manager to revise our proce­dure manual, so I am very familiar with what questions to ask. My goal is to handle each call as quickly and efficiently as pos­sible while still making the patients feel that their needs were met. Every time I take a message, I put it on the corner of my desk, and a file clerk takes it to get the patient’s medical record. In our office we think that telephone conversations are very important. We try very hard to answer all telephone calls promptly and to avoid putting patients on hold. ■

Pagers

Pagers are used in areas with unreliable cell phone service and sometimes in large institutions such as hospitals. A pager (also called a beeper) is like a radio that is always tuned in to a single station. When it “hears” its unique access code signal, it lights up, beeps, or vibrates to indicate that a message is being received. Some pagers are also linked to voicemail. Pagers used by physicians or other health profes­sionals are either numeric or alphanumeric. A numeric pager’s message is a telephone number (e.g., the answering service, the office, the emergency department, home, a col­league). The physician then returns the call to the number on the display. An alphanumeric pager displays an entire message, so the physician can return a phone call or act on the information that is relayed to the pager. Some pagers also include e-mail so that a return message can be sent. If the physicians use pagers, the office staff should have the pager numbers for each physician in the practice.

A simple type of pager may also be used for patients in ambulatory care areas of hospitals or clinics. It is similar to

pagers used in restaurants and lights up and/or vibrates to notify patients when it is their turn. Patients can leave the waiting area and be notified when to return. This type of pager provides patient confidentiality because it eliminates the need to call the patient by name.

Highlight on Analog versus Digital Technology

Until the middle of the 1980s, telephone service used only analog technology, which translates the audio signals from a telephone into electronic pulses. These pulses are usually transmitted along wires that link all telephones together physically. In cordless telephones analog signals are transmitted from the telephone base to the receiver using radio waves. The advantage of analog technology was, and still is, high sound quality with minimal distortion. Analog telephones are also relatively inexpensive. The disadvantage is that analog signals can carry only a limited amount of information. Also, analog signals cannot be encrypted, so the information being transmitted is not secure, especially when a cordless telephone or cell phone is used.

Digital technology converts analog signals from a microphone in the telephone into binary code (consisting of 0s and 1s). The message is transmitted to the receiver through wires or radio signals, where it is converted back into its original signal. Because of the conversion, quality of the signal may be lost, although modern digital equipment has improved in this area. Digital tech­nology is also more expensive. The main advantage of digital technology for the medical office is the ability to transfer elec­tronic data securely using telephone lines. Both voice and com­puter transmissions can be encrypted in such a way that they cannot be intercepted and decoded. The encryption key is neces­sary at the receiving end in order to decode the information.

Digital and analog equipment cannot be connected together without using an adapter. Modern multiline telephone systems are digital. If an analog telephone, modem, or fax machine is connected to a digital system without using a digital-to-analog adapter, it can draw too much current and damage itself or even the entire telephone system. ■

INCOMING CALLS

An incoming telephone call sounds like a routine event. But breaking down the process, it becomes clear that a number of different elements go into answering a routine call.

Centralized or Electronic Routing

Many offices use an electronic routing system to direct calls. At each extension, the telephone may be answered or the call will go to voicemail, and the caller can leave a message for office staff members who are not available. By offering the caller several options (e.g., scheduling an appointment, speaking with the medical assistant, discussing a billing question), the electronic routing system directs the call to the appropriate part of the office, saving the expense of a staff person who would otherwise be answering the call. It also keeps patients from being put on hold, which some people appreciate.

However, other patients find electronic routing of mes­sages confusing and frustrating, especially if the person they need to speak with is not available and does not return calls promptly.

If electronic routing is used, the message should be kept up to date and should be as clear and concise as possible.

In other offices, incoming calls are answered directly by the medical assistant. Although the personal touch is appre­ciated by many patients, when several calls come in at the same time, some callers end up on hold. If the office has several staff members, many of the calls end up being trans­ferred anyway.

Managing Incoming Calls

Performing Telephone Screening

The first step in handling telephone calls is to find out how urgent the call is and what is necessary to handle the call.

Most calls are routine and can be taken in the order in which they come. In most cases a new call is placed on hold while the previous call is handled. However, there are some exceptions:

        Calls from other physicians are put through at once.

        Emergency calls are treated as urgent and receive top priority. They will be discussed in detail later in this chapter.

        If the caller is a relative of the physician, the medical assistant either puts the caller through or speaks to the physician via intercom to determine how to handle the call.

When answering calls, it is polite to obtain the caller’s name and ask permission to place the caller on hold. This gives the caller the opportunity to identify the call as urgent.

After the caller’s name has been obtained, the caller usually states the reason for the call or asks for a staff member or department. When the caller asks for a staff member by name, the medical assistant usually transfers the call. If that staff member is with a patient, the medical assistant may offer to take a message or transfer the call to voicemail. Often the caller asks for the physician. Most physicians do not take calls while they are seeing patients. Additional questions may show that the medical assistant can handle the call, or it may be necessary to take a message for the physician (Procedure 39-1).

Calls the Medical Assistant Usually Handles

The medical assistant usually handles four kinds of calls.

                  Requests to schedule appointments—The medical assis­tant will usually schedule appointments and tests, either in the office or at an outside laboratory or the hospital. This topic is discussed in the next chapter.

                   Billing inquiries—The medical assistant may handle inquiries about a patient bill or insurance. For this type of call, the medical assistant refers to the patient account in the computer and gives the caller the information requested. If the caller’s question is

What Would You Do? What Would You Not Do?

Case Study 1

Channa has answered a telephone call from Jane Weston, who has called to make a routine appointment. Although the patient has been offered several different appointment days and times, none of the choices has been satisfactory. A low buzz indicates a call on another telephone line. Channa is the only person available to take the call. She tells Mrs. Weston that she will need to put her on hold for a minute. Mrs. Weston says, “Please don’t put me on hold. I’ll take that last appointment. What time was it for?” ■

complicated, the call may be referred to a billing specialist or the office manager.

                   Receiving diagnostic test and lab results—The medical assistant can also take calls regarding diagnostic test and lab results. Many lab results today are sent to physicians’ offices by fax or directly on the computer system. But if a laboratory calls in test results, the medical assistant needs to have a blank laboratory slip so that the results can be filled in, along with the patient’s name and the date the tests were taken. After taking the results, the medical assistant pulls the patient’s medical record, clips the results to the front, and places the medical record where the physician can review it. Taking all results accurately is very important.

                   Requests for information—Finally, the medical assis­tant can handle calls requesting information, such as directions to get to the office, office hours, and the office’s medical specialty.

Taking Messages

The medical assistant usually takes messages using a message form. Some forms are pressure sensitive so that a copy is created with the original message. The originals stay in the message book and form a telephone log. If the message form does not create a copy, it is helpful to keep a separate tele­phone log for future reference. In some offices a form is used that has a space for the physician to write orders or desired follow-up on the bottom of the form. The medical assistant should not write in this space when taking the message. If telephone messages are filed in the patient’s medical record after the physician or other recipient has responded to the message, a form with a peel-off backing is preferable.

When taking a message about a patient, the message should include the following information:

        Date and time

        Name of the physician or staff member

        Patient’s full name and date of birth (or age)

        Name of the caller (if not the patient)

        Message or question that indicates clearly what the patient wants (e.g., prescription, laboratory results, medical advice)

        Additional information to clarify the message, such as symptoms, medication and pharmacy information, and actions that have already been taken

        If the patient is ill or requests medication, any medica­tion allergies should be noted

        Telephone number

        Initials of the person taking the message

When a medical assistant transcribes messages from an answering machine or from voicemail, the same message form should be used. The time the call was recorded should be used. The medical assistant may need to play the message more than once in order to record all information (Proce­dure 39-2).

Taking Messages Using the Computer

The medical assistant may work in a facility where tele­phone messages are taken using the computer, either using a stand-alone computer messaging program or using the clinical messaging feature within the electronic medical record. Built-in message templates facilitate taking the message during the telephone call and forwarding the message to one or more recipients. When this feature is part of the electronic medical record, the patient’s medical record can be attached to the message, and the transmission is secure. This can be very useful for questions about lab results and requests to renew prescriptions.

Patients Requesting Test Results

When a patient calls requesting test results, the medical assistant should find out when and where the test was done and take a message for the physician. After the call, the medical assistant should locate the medical record, be sure the results of the laboratory or diagnostic test in question are in the record, and leave the message and medical record for the physician. It may be office policy to use a sticky paper flag to identify the report in the medical record. Some offices choose to send patients letters about laboratory results, which cuts down on the number of telephone calls requesting information, especially for routine tests. After reviewing the laboratory or diagnostic test results, the physi­cian may instruct the medical assistant to call the patient back to give the results, to schedule follow-up testing, and/ or to ask the patient to schedule an appointment to discuss the results.

Patients Reporting Satisfactory or Unsatisfactory Progress

Physicians often tell a patient to call and check at a specified interval after a visit, to report on how a condition is resolving after treatment. If the patient reports satisfactory progress, the medical assistant should take a brief message, clip it to the chart, and leave it for the physician. An unsatisfactory report should generate a more complete message, and the chart should be pulled and the message clipped to it so that the physician can call the patient. When a patient gives a progress report on the telephone, either the original message should be filed in the patient record or the medical assistant should document the telephone conversation in the record.

Requests for Medication or Prescription Refills

Often patients or pharmacies call with requests to have prescriptions refilled or renewed. When the pharmacy calls, it is important to get the patient’s name and date of birth, name of the medication, dosage, and amount of medication prescribed. When the patient calls, it is important to get the name of the medication, dosage, and how often the patient takes it. In addition, it is important to determine how the patient wants to receive the medication (from the pharmacy or by mail order). It is helpful to verify the information in the patient’s medical record when an electronic medical record is used. Otherwise the message should include the name, telephone number, and location of the pharmacy or mail order company. It is more common for a physician to prescribe using a computer program, but if this is not the case, a written prescription should be sent to the patient if mail order is specified. If the medication is an antibiotic or a controlled substance used for pain relief, the medical assistant should ask about symptoms that would require a refill. The medical assistant should tell patients to check with the pharmacy the next day unless they hear from the physician or office. A message to request medication is also clipped to the patient’s medical record. Physicians often follow up directly with the pharmacy, especially if they are using an electronic prescription routing service, but in some offices the physician writes the prescribing information on the bottom of the message for the medical assistant to call in to the pharmacy. When medical assistants call in pre­scriptions, they should always note this in the progress notes and/or medication record (Procedure 39-3).

Calls for Referrals or Requesting Laboratory or Diagnostic Tests

A patient may call to say he or she needs a referral (because of a particular insurance company’s policy) to see a specialist outside the medical group or to have a laboratory test or diagnostic procedure done.

The medical assistant takes the necessary information (what type of referral, for what, to whom) on a message form for the physician. If a referral is appropriate—or neces­sary because of an insurance company or health mainte­nance organization policy—the medical assistant may complete a paper or electronic form. If the patient is asking for a laboratory test, such as a throat culture, the medical assistant should fill out the laboratory form for the patient to pick up or should enter the information into the com­puter, after verifying with the physician that the requested test is appropriate. The physician may ask the medical assis­tant to call the patient and schedule an appointment before authorizing the referral.

Pafients with Medical Questions

For patients with medical questions, the medical assistant takes a message for a physician or refers the call to another staff member designated by the office to handle such calls. The office should have written guidelines to follow if a medical assistant screens medical questions. The medical assistant should follow the written guidelines closely and take a message for the physician about any concern or ques­tion that falls outside the preset guidelines.

What Would You Do? What Would You Not Do?

Case Study 2

Mary Woodward, a 62-year-old woman with hypertension, has called because she has run out of her blood pressure medication. Mrs. Woodward tells Channa that the medication is atenolol and she is pretty sure that the dose is 50 mg every morning. When Channa asks for the pharmacy telephone number, Mrs. Wood­ward says, “It’s the Best Buy Pharmacy in Whittier. You must have the telephone number. I don’t know what it is offhand.” Channa checks the computer and finds that the office does not have a record of the pharmacy telephone number. ■

Calls from Other Physicians

Calls from other physicians are usually put through right away, even if the physician is examining a patient. If the medical assistant has to find the physician, this may be given as a reason to place the caller on hold briefly, but the medical assistant should locate the physician as quickly as possible and explain which physician is calling. The physi­cian may ask the medical assistant to transfer the call to another extension to avoid talking in front of a patient.

Calls from Salespeople

Often a sales representative from a pharmaceutical company or equipment company calls before visiting the physician’s office. Salespeople are usually seen by the office manager, who gives the information to the physician. Drug represen­tatives sometimes drop by, but if they hope to talk to the physician they usually must call and ask for an appoint­ment. Physicians usually schedule sales representatives during lunch. The physician has to agree to see the representative before a medical assistant makes an appointment.

Urgent or Emergency Calls

If a patient calls with a medical problem, the medical assistant asks questions to determine how urgent the problem is. After obtaining the caller’s name and telephone number and iden­tifying who has the problem (the patient’s name, age or date of birth, and relationship to the caller), the medical assistant should obtain the patient’s symptoms and current condition. In most offices there is a guide to telephone screening in the office procedure manual. This helps the medical assistant identify which questions to ask in order to determine how urgent the problem is. In the next chapter, there is a more complete discussion on the kind of appointment to offer a patient based on the symptoms the patient reports.

If the medical assistant determines that the call represents an urgent problem or emergency, he or she should follow office policy. The call should be referred to a physician if one is in the office; in a group practice, one physician may be assigned at all times to take urgent calls. If there is no physician in the office, a nurse practitioner or physician’s assistant may be assigned to take urgent calls. If no licensed professional is present in the office, the medical assistant must advise the caller or contact the on-call physician. The following are the guidelines for dealing with such a call:

                  If the emergency is serious or life-threatening, the caller should be instructed to call an ambulance by dialing 911. This activates the emergency medical services (EMS) system. If the caller is a child or seems upset or confused, the medical assistant can offer to call an ambulance for the caller.

                   If the emergency is a case of poisoning, the caller should be instructed to call the local poison control center. The telephone number of the poison control center (1-800-222-1222) should be placed next to every telephone in the medical office. Even if it is a case of poisoning, if the patient is unconscious or not breathing, the caller should be instructed to call an ambulance.

                   If the patient has a problem that requires treatment in an emergency department but is conscious and able to walk (e.g., a fractured arm), the caller should be instructed to take the patient to the nearest emer­gency department or call an ambulance. If the patient is alone, an ambulance should be called.

                   If the patient’s problem is usually treated in the office, the patient should be given an appointment for that day.

                   If the condition of the patient is not life-threatening and/or the medical assistant is unsure how urgent the problem is, the physician should be contacted for instructions either by cell phone or pager. If there is any doubt about how serious the patient’s condition is, it is safer to instruct the patient to call an ambulance and/or go to the hospital emergency department.

Whenever an urgent call is handled, the medical assistant should fill out a message form to be sure that the informa­tion has been written down. Either the message form or the instructions given to the patient should later be documented in the medical record. If a patient has been instructed to go to the emergency department, the physician should be noti­fied promptly.

Dealing with Problem Calls

The Caller Who Refuses to Give Information

When callers ask for a physician and refuse to identify themselves, it is probably because they want to speak to the physician but suspect that if they give a name, they will be asked to leave a message. The medical assistant should explain politely that the physician is not available and offer to take a message. If the caller still refuses to give informa­tion, the medical assistant can instruct the caller to write a letter to the physician and mark it “personal.”

Complaints

The medical assistant should listen carefully to callers with complaints, avoid getting defensive or angry, and ask for specific information. It is important to remain calm so that a professional demeanor is maintained. The medical assis­tant should state clearly what he or she can and will do. It may be necessary to refer the matter to the office manager or the physician, but the medical assistant should get as much information as possible at the initial contact.

It is important to avoid hanging up on an angry caller. It is usually possible to calm a caller down as long as the medical assistant does not raise his or her voice and does not become defensive. The caller should be told a specific time when he or she can expect to hear back from someone in the office.

Patients with Special Problems

If a patient calls who is confused or has difficulty with English, the medical assistant should listen carefully and try as hard as possible to understand. The medical assistant may speak more slowly than usual but should not speak more loudly. If it is impossible to communicate, even using simple language, the medical assistant should try to at least obtain the caller’s name and telephone number. Then it may be possible to find out from the medical record if the patient speaks a different language or if there is an emergency contact number. If the person seems confused, the medical assistant should ask if there is another person with whom he or she can speak because this may be a medical emer­gency. The medical assistant may need to ask for guidance from the physician or office manager.

PROCEDURE 39-1 Performing Telephone Screening

Outcome Screen incoming telephone calls.
Equipment/Supplies 
• Telephone• Appointment book or computer terminal
• Message pad• Clock or watch
• Pen or pencil 

PROCEDURE 39-1

         Procedural Step. Answer every telephone call within the first three rings.

Principle. Callers become annoyed when their calls are not answered promptly.

         Procedural Step. Identify the medical office and give your name. Each practice will have a preferred way for all employees to answer the telephone. Example: “Primary Care Associates, this is Channa speaking.” Do not rush through the greeting. The caller needs to hear this first sentence clearly.

Principle. Callers need to know what business they have reached and with whom they are speaking. Oth­erwise they will have to ask if this is Primary Care Associates.

         Procedural Step. Listen carefully to what the caller says, and decide as soon as possible whether this is a call you can handle, whether you need to take a message, or whether the call should be transferred to someone else in the office.

Principle. The caller does not want to have to repeat all the details if the call must be transferred. If you need to take a message, begin writing.

         Procedural Step. Ask for the caller’s name. “May I ask who is calling?”

Principle. You will need the caller’s name to address the caller by name, to take a message, or to identify the caller before transferring the call.

         Procedural Step. If you can handle the call, such as a call for an appointment, do so promptly.

         Procedural Step. If you need to take a message, see Procedure 39-2, Taking a Telephone Message.

         Procedural Step. If you need to transfer the call to someone else in the office, place the caller on hold, noting the caller’s name and the extension. Tell the person you are transferring the call to who is calling and what extension the call is on.

Principle. It is a courtesy to tell the person you trans­fer a call to who is calling; he or she must be able to locate the call if more than one line has a call on hold.

          Procedural Step. If the caller describes symptoms that require immediate care, ask questions to assess the problem, following guidelines in the office proce­dure manual. If there is a physician or other licensed

professional in the office, transfer the call immedi­ately. Otherwise, assess the urgency of the problem and follow up according to office guidelines. If the patient’s health is at risk, instruct the caller to call 911. Principle. Patients expect correct medical advice from a health care facility when they have urgent medical problems.

9. Procedural Step. If your telephone has more than two lines, it is helpful to keep a list of the names of callers and extensions. When a call is on hold, the light for that telephone line blinks. If you have transferred a call but the call remains on hold, within 30 to 45 seconds you should determine if the caller is still holding; if so, you should try to transfer the call again or take a message.

Principle. Sometimes a transfer does not go through or the call is not picked up. The caller has no way to get back in contact with you to leave a message or ask to speak to someone else.

             Procedural Step. If the telephone rings for another call, ask if you may put the caller you are speaking to on hold and wait for the caller to agree. After pressing the hold button, answer the other call and explain that you are speaking to a caller on another line. Give the second caller the option to hold and wait for you or take their number and offer to call back as soon as you are finished.

Principle. In general calls are handled in the order they are received. By asking for permission to put the caller on hold, you give the caller a chance to tell you if it is an emergency. Some callers prefer to hold; others prefer to be called back. Time passes slowly when a caller is on hold, and the caller may become tired of waiting and wish to leave a message.

             Procedural Step. At the end of the call, repeat any information you have discussed (such as the date and time of an appointment). End the call politely by thanking the caller (if appropriate) and saying goodbye.

Principle. Confirmation helps avoid misunderstand­ings. Thanking the caller and closing the conversation demonstrates telephone courtesy.

Outcome Take a telephone message.

Equipment/Supplies

                                                                                                                                                                           Telephone          • Pen or pencil

                                                                                                                                                                           Computer            • Clock or watch

         Message pad

         Procedural Step. If you determine that the person to whom a telephone caller wants to speak is not available, offer to take a message.

Principle. A message is a way of communicating to a person who is not available to speak on the telephone.

         Procedural Step. Give the caller a reason why the person cannot take the call. Acceptable reasons are as follows: busy with a patient, not at his or her desk, not in the office, on another line. Generally physicians do not take calls except possibly during specified hours. Patients who ask for the physician are told that the physician is not in the office or that the physician is busy with patients.

Principle. Most callers are willing to leave a message if they understand why their call is not being answered.

         Procedural Step. Fill in the information on the message form or in the computer messaging program, including the name of the caller, business affiliation (if any), date, time of the call, telephone number including area code, and information the caller wishes to leave about the reason for the call. Place your initials on the message in case there are questions. If there is a section at the bottom for a response to the message, leave that area blank.

Principle. Complete information is necessary for a call to be returned.

Procedural Step. Verify the information. If possible, give a time when the call might be returned. If the message recipient does not have a scheduled time to return messages, say, “I will give him (or her) the message.”

Principle. Callers like to know when to expect a return call.

DOCTOR – STAFF RESPONSE

Doctor’s / Staff Orders / Follow-up Action

Fill in the information on the message form.

         Procedural Step. End the call politely.

         Procedural Step. If the call is from a patient or con­cerns a patient, pull the medical record and clip the message to it or attach the medical record in a clinical messaging computer program.

Principle. This ensures that information about the patient is available and the action taken on the call can be documented if necessary.

         Procedural Step. Place the message (with the patient record, if needed) where the person for whom it is intended expects to find messages. This may be on a desk or in a mailbox. If a computer messaging program was used, send the message to the intended recipient(s) using clinical messaging or e-mail.

8. Procedural Step. Perform follow-up according to office procedure.

Principle. This ensures that important issues do not fall through the cracks.

PROCEDURE 39-3 Taking Requests for Medication or Prescription Refills

Outcome Take a message requesting medication or a prescription refill.

Equipment/Supplies

         Telephone                                                                                             •    Pen or pencil

         Computer                                                                                              •    Medical record

         Message pad                                                                                        •    Clock or watch

         Procedural Step. Identify the caller and telephone number.

         Procedural Step. Identify if the caller is a patient or a pharmacy.

         Procedural Step. If the caller is a patient, take the information about the medication requested, dose, and number of times a day the patient takes the medication. Write down or enter into the computer the name and telephone number of the patient’s preferred pharmacy or mail order supplier.

         Procedural Step. If the caller is a pharmacy, usually the medical assistant takes a message, including the name and address of the patient, the medication requested, and the dosage and amount of medication to be pre­scribed. Inform the pharmacy when the physician is likely to approve the refill so that the pharmacy can tell the patient.

Principle. Usually physicians have specific times when they review and respond to messages.

         Procedural Step. End the call politely.

6. Procedural Step. Follow usual procedures to attach the patient’s medical record to the message (either manu­ally or electronically) and place the message where the physician can review it, or send the message electroni­cally. If the physician responds directly to pharmacy calls, put the pharmacist on hold, pull the patient’s medical record, and give it to the physician before transferring the call.

Principle. The physician will need to review informa­tion about the patient before agreeing to refill or pre­scribe medication.

Procedural Step. Usually the physician fills the pre­scription directly by computer, indicates on the message slip whether the prescription may be refilled, or writes a new prescription on the message slip. The medical assistant can then call the pharmacy with the informa­tion. Read the prescription from the message slip exactly as the physician has written it.

Principle. The medical assistant functions as an agent of the physician in this case. He or she must give the exact information the physician has indicated.

The physician may write prescription information on the message form.

8. Procedural Step. Document the refill or prescription in the patient’s medical record. In some offices the message itself is filed in the medical record, and in others the medical assistant writes the information in the progress notes of the medical record.

Principle. Any treatment of the patient must be docu­mented in the medical record as part of the continuous record of care given. See Chapter 26 for specifics on documenting medications.

CHARTING EXAMPLE

Date 
10/13/XX4:30 p.m. Prescription called to Westside
 Pharmacy for Aldactazide 25 mg tabs, #30,
 Sig: i po q am, 12 refills.—————————————-
 —————————– K. Anderson, CMA (AAMA)

OUTGOING CALLS

More calls come into the office than go out. But there are certainly enough outgoing calls. Medical assistants make many of them. Outgoing calls a medical assistant may make include calls to patients, suppliers, insurance companies, other medical offices, laboratories, pharmacies, and hospi­tals. In some systems it is necessary to dial the number 9 before the telephone number in order to get an outside line. Local telephone books are still provided by the telephone service provider, although it is also possible to look up telephone numbers using the Internet.

Local Calls

Calls to patients, whether the matter is medical or financial, should not be made from the front desk unless a privacy window is closed. The medical assistant must prepare infor­mation and supplies before making the call. If the medical assistant is calling a patient, the patient’s medical record should be at hand with any notes from the physician. If the call is picked up by an answering machine, it is permissible to leave your name, practice name, and telephone number for the patient to call back. Because the patient’s family members may have access to the answering machine or voicemail, no medical information should be included in the message (Procedure 39-4).

It may be necessary to call a patient about an overdue account. The medical assistant should not call the patient at work for this type of call or discuss billing information with anyone other than the person responsible for the bill.

For calls to laboratories, hospitals, or suppliers, the medical assistant should be sure to have organized the infor­mation necessary to complete the call before dialing the telephone number.

What Would You Do? What Would You Not Do?

Case Study 3

The physician asks Channa to schedule an appointment for Andrew Page, a 35-year-old man whose recent lipid profile shows an elevated cholesterol and triglyceride level. This is a change from previous laboratory work. The physician says to tell the patient that he wants to discuss the recent blood work in person. When Channa calls the patient, his wife answers the telephone. Channa identifies herself and the medical office and asks to leave a message for Mr. Page to return her call. Mrs. Page says, “He’s away on a business trip until Thursday. What is this about? Is it really important?” ■

If the medical assistant places a call for one of the office’s physicians, the physician must be ready to talk before the call is placed. As soon as the physician being called is located, the medical assistant connects the physician placing the call.

Medical assistants and other office staff should not make or receive personal calls using the office telephone system except for emergencies, both to avoid tying up the tele­phone and because telephone calls take time away from work. The medical assistant can check messages and make outgoing calls during breaks or at lunchtime using a pay phone or personal cell phone. Although permission may be given to make an urgent call using the office telephone, a personal long-distance call is never appropriate.

Appointment Reminders

Medical assistants may be asked to place reminder tele­phone calls to patients 24 to 48 hours before their scheduled appointments. The HIPAA Privacy Rule allows health care providers to call patients and leave messages regarding their care as long as the patient has not requested confidential communication. It is recommended to limit the informa­tion left in a message to the minimum required to confirm the appointment.

Medical offices have begun to use computer programs that interface with scheduling programs and call patients automatically 24 to 48 hours before a scheduled appoint­ment. They provide a recorded message about the appoint­ment and will leave a message if no one answers the telephone. It may be possible to confirm or cancel the appointment after receipt of the message. The patient is instructed to call the office with any questions and some­times to confirm or cancel the appointment if a message has been left.

Long-Distance Calls

Long-distance calls are almost always dialed directly. The tele­phone number for a long-distance call can be obtained from directory assistance (411). The medical assistant should know what kind of calling plan the office has because the time of a call can make a difference in the rate for long-distance calls. When calling distant locations, it is important to be aware of the different time zones. To make international calls, the medical assistant should dial 1, then the country code, then the telephone number. In order to prevent unauthorized long­distance calls, most offices have a code that must be used to access the long-distance system. Long-distance services may also be limited to one or two extensions.

Conference Calls

Some phone systems allow conference calls among three or more parties, such as a physician and other individuals who are being called at different telephone numbers. If the tele­phone system allows this, the medical assistant should learn how to set up such calls for the physicians.

PROCEDURE 39-4 Telephoning a Patient for Follow-Up

Outcome Place an outgoing telephone call to a patient for follow-up.

Equipment/Supplies

        Telephone

        Scratch paper

        Pen or pencil

         Procedural Step. Organize all materials that may be necessary during the telephone call. Schedule calls during business hours.

Principle. Preparation allows calls to be made more efficiently.

         Procedural Step. Write the telephone number on a piece of paper. Include the area code and a country code, if necessary.

Principle. It may be difficult to remember the number, especially if you do not reach the number on the first attempt.

         Procedural Step. Place the call. When it is answered, ask for your party. Identify yourself with your practice name and your name (“This is Channa from Primary Care Associates”).

         Procedural Step. If you reach an answering machine, identify yourself with your practice name and your

Material necessary to place the call, such as a telephone book, instructions from physician, and/or patient medical record

name and ask the intended recipient to call you back. Leave your telephone number with area code. Principle. Unless it is an appointment reminder, the subject of the telephone call should not be left on an answering machine to protect patient confidentiality.

         Procedural Step. If you are speaking to the patient, give the information requested by the physician. This may be an instruction to make an appointment or may include laboratory results. Do not give more informa­tion than the physician has authorized.

Principle. As an agent of the physician, you have limited authorization to provide information.

         Procedural Step. If the patient has additional ques­tions, offer to take a message for the physician.

         Procedural Step. Close the call politely. Repeat instruc­tions if any were given.

Channa Eng: I was terrified of the telephone when I first started my externship. It was a busy clinic, and I started out in adult medicine. In the morning, I sat at the front desk to check patients in, take copayments, and answer the telephone. I was always afraid that I wouldn’t know what to say. We got the callers who wanted to speak to someone in person, so you never knew what to expect. My supervisor told me to answer each call with the name of the clinic and my own name, and then ask how I could help the caller. If I didn’t know how to handle the call, I was supposed to put the caller on hold and ask Mary Lynn, the other medical assistant, for guidance. One call that I remember particularly was from an older woman who seemed lonely and confused. She asked for her physician, but she was willing to leave a message when I told her that the physician didn’t take calls while he was seeing patients. She said that she couldn’t remember if she was supposed to take her blood pressure medication once a day or twice a day and she wasn’t sure if it was one pill or two pills. She told me that her daughter set up her pills in a pill container every week but she had forgotten if she should take them both in the morning or one in the morning and one at night. I told her to get the bottle of medication and read the label to me. From the label we determined that she was supposed to take two pills every morning. She thanked me, and I indicated on the message form that we had clarified the problem. After the call, Mary Lynn com­plimented me for being so helpful and for handling the call by myself. After that I began to feel more confident about taking telephone calls. ■

MEDICAL PRACTICE and the LAW

Recognizing and Responding to Medical Emergencies

When a telephone call concerns a life-threatening or serious emer­gency, the medical assistant becomes legally responsible to provide appropriate assistance, even if the medical office is not equipped to provide the actual care needed. Once the medical assistant has identified an emergency, he or she must maintain contact with the caller, help the caller get assistance, and follow up to be sure that care was received.

Good Samaritan laws generally do not apply to the medical office because people expect to receive medical care and/or medical advice from physicians and medical offices.

The most desirable response is to refer an emergency or urgent call to a physician or other licensed health care provider in the office (nurse practitioner, physician’s assistant, or licensed nurse). However, if no licensed professional is able to take the call, the medical assistant should assist the caller. The medical assistant should assess the situation and instruct the caller to arrange transportation to an emergency department if the patient’s health will be harmed by delayed treatment.

The following guidelines describe an appropriate response to an emergency call:

                 Medical assistants should always ask if they may put the caller on hold and wait for a response. This gives the caller an opportunity to state that the call is truly urgent or an emergency.

                 Every medical office should keep an updated procedure manual near the telephone. The manual should list specific urgent problems and situations, specific questions to ask, and responses to the caller’s questions. A list of emergency numbers should be placed near all telephones; these include the numbers for the EMS system (usually 911); the number for the poison control center; and the pager numbers or cell phone numbers for all the physicians in the practice.

                 Medical assistants should write down a caller’s name and telephone number as early in the call as possible, in case the call is interrupted. Keeping a telephone log provides documentation of how calls were handled.

• If the medical assistant believes delay in treatment poses a threat to the health of the ill or injured person, the caller should be instructed to call an ambulance. If the caller is a child or seems too confused or anxious to make the call, the medical assistant can call 911. The location of the emergency should be determined before the call is made. It is preferable to use a different line to place a call to an ambulance so that contact can be maintained with the caller.

After a caller has been instructed to call an ambulance, there are several steps that follow. The medical assistant should notify the physician (if this has not already been done) and call the emergency department at the local hospital to inform them that one of the practice’s patients will be coming in. If the injured or ill person is a patient of the practice, this should be noted in the patient’s medical record. If the injured or ill person is not a patient of the practice, an incident report should always be completed. See Lecture 48 to learn how to fill out an incident report. ■

What Would You Do? What Would You Not Do? responses

What Did Channa Do?

           Spoke politely, and told Mrs. Weston that she needed to pick up the other call.

           Gave Mrs. Weston the choice of being placed on hold or being called back.

           Assured Mrs. Weston that she would get back to the telephone call with her as soon as possible.

           Kept her voice calm and friendly.

What Did Channa Not Do?

           Did not let the second telephone call ring more than three times.

           Did not promise Mrs. Weston that she would put the other call on hold immediately.

           Did not try to rush through the call with Mrs. Weston without making sure that she was clear about the appointment date and time.

What Would You Do/What Would You Not Do?

Review Channa’s response and place a checkmark next to the

information you included in your response. List the additional infor­mation you included in your response.

What Did Channa Do?

          Told Mrs. Woodward to get the bottle of pills, which has a record of the dose and the pharmacy telephone number.

          Told Mrs. Woodward she would place her on hold; instructed Mrs. Woodward to stay on the line after finding the medication bottle.

          Gave Mrs. Woodward the option of calling back when she had found the bottle of pills.

          If Mrs. Woodward seemed confused or distressed, Channa could verify the medication dose from the patient’s medical record and look up the telephone number of the pharmacy.

          Remained calm and friendly.

          Made sure to follow up and complete the message.

What Did Channa Not Do?

          Did not become impatient or tell Mrs. Woodward that she should know she needed her bottle of medication ready when she called to ask for a refill.

          Did not pass on the message without confirming that Mrs. Woodward had asked for the correct dose of medication.

          Did not pass on the message without a pharmacy telephone number.

What Would You Do/What Would You Not Do?

Review Channa’s response and place a checkmark next to the information you included in your response. List the additional infor­mation you included in your response.

What Did Channa Do?

           Reassured Mrs. Page that it was not an urgent matter, but said she hoped Mr. Page would return her call after his trip.

           Told Mrs. Page politely that she could not discuss the matter with anyone but Mr. Page.

What Did Channa Not Do?

           Did not tell Mrs. Page exactly why she was calling her husband.

           Did not tell Mrs. Page that the matter was not important.

           Did not ask Mrs. Page to contact her husband before he returned from his business trip.

           Did not tell Mrs. Page that the physician could give her more information about the matter.

What Would You Do/What Would You Not Do?

Review Channa’s response and place a checkmark next to the information you included in your response. List the additional infor­mation you included in your response.

TERMINOLOGY REVIEW

Medical Term Word Parts Definition

Enunciation

Pager

Personal digital assistant (PDA) Smartphone Voicemail

The act of speaking clearly and concisely.

An electronic device that notifies the recipient to receive a message or return a telephone call. A portable handheld computing device with access to various reference tools, such as a drug reference, calculator, and address book.

A cell phone with computer capabilities.

A method for delivery, storage, and retrieval of telephone messages that is built into the telephone system.

^ ON THE WEB

For information on the Health Insurance Portability and Accountability Act (HIPAA) and appointment reminders:

U. S. Department of Health and Human Services:

http://www.hhs.gov/ocr/privacy/hipaa/faq/smaUer_providers_and_businesses/286.html For information on poison control centers:

American Association of Poison Control Centers: www.aapcc.org For information on time zones:

The Official U.S. Time: www.time.gov