On-call coverage has to be clear: who’s on call, how they’re reached, and what gets documented. Ambiguity leads to missed calls and compliance issues.
Who’s on call and how
Rotate on-call among qualified staff. They need a phone and a way to access the schedule and basic patient info (within HIPAA). Define what “on call” means: are they at home and available, or do they have to be within a certain drive time? Put it in policy.
Escalation and documentation
When a patient or family calls, the on-call person triages: advice, visit, or 911. Document the call, the decision, and any follow-up. If a visit was made, it goes in the chart. Surveyors may ask how on-call works and who’s responsible; align with the Conditions of Participation and have it in policy and in practice to avoid citations. We have an on-call procedure template you can download: rotation, escalation, and documentation requirements. Use the button below to get it.