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OBJECTIVE: The objective of this study was to describe the nursing documentation of telephone communication with physicians in community nursing homes. DESIGN: We conducted a prospective observational study evaluating nursing documentation of all telephone calls to one physician group. SETTING: We studied two proprietary community nursing homes in Baltimore, Maryland. MEASUREMENTS: Data were collected by physicians at the time of each call regarding the time, day, nursing facility, reason for the call, and any orders given. Calls were also categorized as to whether documentation was necessary by defined criteria. The nursing home charts were then reviewed for the presence of documentation of 1) the issue that prompted the call, 2) physician's participation in the matter, and 3) any orders given by the physician. The relationships between the characteristics of the telephone calls and the rates of documentation were then analyzed. RESULTS: There were 248 calls from the two nursing homes during the 2-month study period. Nursing documentation of the issue that prompted the call was present for 80% of total calls. This documentation was more likely to be present with calls for change of patient status and notification of laboratory/radiograph results compared with calls for other issues (117 of 125 [94%] vs. 57 of 63 [90%] vs. 24 of 60 [40%], respectively; chi(2) = 78.3, P <0.0001). Calls that were categorized as "documentation necessary" by the Medical Director were more likely to be documented than calls that were not (132 of 150 [88%] vs. 9 of 35 [26%], respectively; chi(2) = 60.8, P <0.001). Of the 198 calls with any form of documentation, specific mention of physician participation in the communication was present in 89% of these calls. This documentation of physician participation was more likely to be present with calls for laboratory/radiograph notification than with calls for change of patient status or calls for other reasons (57 of 57 [100%] vs. 99 of 117 [85%] vs. 20 of 24 [83%], respectively; chi(2) = 10.0, P = 0.007). Physicians indicated that orders were given during 69% of calls, but orders were only documented for 79% of these interactions. No characteristics of the call were associated with likelihood of order documentation. CONCLUSIONS: In this study, documentation of issues that lead to telephone calls to physicians was not always present. Similarly, orders given by the physician were absent over 20% of the time. Nurses, physicians, and facilities should develop efficient and routine strategies to optimize rates of documentation of telephone communication with physicians.