Policies and Procedures Checklist

For telephone health care to be delivered in a safe and consistent manner, the program must develop and maintain a current manual of policies and procedures to which the staff can refer. These must be evidence based, specific to your practice area, and reviewed by the medical director, nursing director, staff utilizing them, and depending on your organization, legal counsel may want to review them as well.

Suggested partial sample of policies and procedures that your program should consider:


Call back policies
  • Caller hangs up on nurse
  • Caller is suicidal
  • Minor or surrogate callers
  • Threatening calls
  • Suspected child abuse
  • HIPPA considerations
  • Caller refuses help
  • No answer
  • Busy signal
  • Caller ID block
  • Wrong number
  • Unidentified answering machine


High Acuity Calls
Drug overdose, penetrating wounds, CVA, chest pain, etc,

Frequently Encountered Situations

  • Taking a temperature (teaching)
  • Assessing respiratory patterns over the phone
  • Measuring medication (teaching)
  • Transportation of sick person
  • After hour sites for patients to be seen
  • Normal human resource policies and procedures for running a business
  • Unable to reach the MD on call
  • Handling of patient complaints
  • Organizational chart for problem-solving of issues
  • "3 times You're Out" for callers who call 3 times, about the same issue, in a 24 hour period
  • Overriding of protocols
  • Caller with a language or hearing barrier
  • Symptoms not covered by a protocol
  • Nursing follow up calls



RnCeus Homepage | Course catalog | Discount prices | Login | Nursing jobs | Help

©2009 RnCeus.com