Use this SOP to document and route patient telephone calls safely, protect confidentiality, and ensure that only appropriately licensed personnel provide medical advice, evaluate symptoms, or determine treatment priorities and levels of care.

⚠ Medical Advice Restriction

Front-office staff, back-office staff, receptionists, medical assistants, office managers, clerical personnel, and other unlicensed personnel must never give medical advice or independently tell a patient to go to urgent care or an emergency room. Immediately route the call to licensed personnel.

📚 Resources Needed

The patient’s medical record or electronic health record
The approved telephone message form
A current list of licensed clinicians available to receive calls
The clinic’s emergency-response and ambulance-contact process
The designated location or work queue for routine telephone messages

✅ Before You Start

All telephone calls from patients with problems or medical questions must be documented with the date, time, return telephone number, and message details and promptly brought to the provider’s attention.
Only a physician, licensed registered nurse, or other licensed non-physician medical practitioner acting within their scope—such as an authorized nurse practitioner or physician assistant—may give medical advice over the telephone.
The California Board of Vocational Nursing and Psychiatric Technician Examiners determined that the Licensed Vocational Nurse Practice Act does not permit an LVN to perform triage independently (MCPB Letter 92-15). An LVN may observe and collect data related to a basic physical assessment but may not independently evaluate or interpret the data, perform independent telephone triage, or determine treatment priorities or levels of care.
Unlicensed personnel may provide patient information or instructions only when the physician has authorized the exact information or instruction.
Only a provider or authorized mid-level practitioner may renew or change a prescription.
Call classification by unlicensed staff is used only to prioritize routing. It is not independent clinical triage or medical advice.

📘 Instructions

Step 1 Protect Confidentiality

Handle every call confidentially.
Do not release patient information over the telephone. Follow the clinic’s identity-verification and authorization procedures before any licensed team member discusses protected information.
Speak discreetly and avoid discussing patient information where unauthorized people can hear the conversation.

Step 2 Open The Patient Record And Document The Call

Open the correct patient record before documenting the message.
Record the date and time of the call, the caller’s name and relationship to the patient when applicable, the patient’s return telephone number, and the caller’s exact concern or question.
Use objective words. Do not interpret symptoms, diagnose, recommend treatment, or decide the appropriate level of care.
Complete the approved telephone message form for every call and make the form part of the patient’s medical record.

Step 3 Follow Role And Relay Restrictions

Receptionists must not relay any medical information from the patient or the provider.
A medical assistant working in the front office may relay medical information received directly from the provider, but must not interpret, alter, expand, or add recommendations to the provider’s message.
Receptionists, medical assistants, office managers, clerical personnel, and other unlicensed staff must tell callers that medical advice can be obtained only from an appropriately licensed clinician.
Immediately refer medical questions and symptom-related calls to the physician, physician assistant, nurse practitioner, registered nurse, or other authorized licensed practitioner.

Step 4 Identify The Routing Priority

Ask only the questions needed to determine whether the call should be routed as emergent, urgent, or routine. Do not independently evaluate the patient, interpret clinical data, or determine treatment priorities.

Emergent — Serious injury, serious illness, chest pain, or another report suggesting an immediate emergency. Required routing: Mark the form “Emergent” and carry or send it immediately to the appropriate licensed medical person.
Urgent — The patient is ill or injured and reports needing medical advice or to be seen that day. Required routing: Mark the form “Urgent” and carry or send it promptly to the appropriate licensed medical person.
Routine — The concern is not reported as urgent or emergent. Required routing: Mark the form “Routine” and place it in the designated area or work queue for the appropriate person to process.

Step 5 Handle An Emergent Call

Immediately alert and transfer the call to the appropriate licensed medical person. The licensed clinician directs the patient to the nearest emergency room when required.
Ask whether the patient needs ambulance transportation and assistance calling for an ambulance.
Provide the necessary emergency number or place the call for the patient when requested. Use 911 for an immediate emergency.
If the receptionist places the emergency call, obtain the patient’s name, address, telephone number, all pertinent information available from the caller, and where the patient will be reporting.
Write “Emergent” on the telephone message form and carry or send it immediately to the appropriate licensed medical person.
The emergency-routing steps above do not authorize unlicensed personnel to independently evaluate symptoms or give medical advice.

Step 6 Handle An Urgent Call

Complete the telephone message form for a patient who is ill or injured and reports needing medical advice or a same-day visit.
Write “Urgent” on the form.
Carry or send the message promptly to the appropriate physician, physician assistant, nurse practitioner, registered nurse, or other authorized licensed practitioner.
Do not promise a same-day appointment, recommend urgent care, or provide treatment instructions unless a licensed clinician has authorized the exact message.

Step 7 Handle A Routine Call

Complete the telephone message form and label it “Routine.”
Place the form in the designated area or work queue for the appropriate person to process.
Do not allow a routine label to delay review if the caller later reports an urgent or emergent concern.

Step 8 Process Advice And Prescription Messages

Licensed personnel document all medical advice given over the telephone in the patient’s medical record.
When an authorized provider gives instructions for an unlicensed team member to relay, repeat only the exact approved information and document the provider’s name, the instruction relayed, the date and time, and the patient’s response.
Route every prescription renewal or change request to the provider or authorized mid-level practitioner. Unlicensed staff must not approve, renew, or change a prescription.

🛠 Troubleshooting

A Caller Asks Whether They Should Go To Urgent Care Or The Emergency Room

Unlicensed staff must not make that decision. Keep the caller on the line when possible and immediately connect or alert licensed personnel. If the caller describes an immediate emergency or requests ambulance assistance, follow Step 5 and the clinic’s emergency-response process.

A Licensed Clinician Is Not Immediately Available

Do not give advice or guess. Mark and route the message according to the reported priority, notify the site leader, and follow the clinic’s escalation process. For an immediate emergency, assist with calling 911.

The Caller Requests A Prescription Change

Document the request and route it to the provider or authorized mid-level practitioner. Do not suggest a dosage change, discontinuation, substitution, or refill approval.

A Provider Message Is Unclear

Do not interpret or paraphrase the clinical meaning. Return the message to the provider for clarification before relaying it to the patient.

✅ Completion Check

The call was handled confidentially.
The date, time, return telephone number, caller details, and exact message were documented.
The telephone message form was labeled Emergent, Urgent, or Routine and added to the patient’s medical record.
The message was routed promptly to the appropriate licensed practitioner.
No unlicensed employee independently evaluated symptoms, gave medical advice, or determined the level of care.
Any provider-authorized instruction was relayed exactly and documented.
Prescription renewals or changes were handled only by the provider or authorized mid-level practitioner.

References

Medical Board of California Medical Assistant FAQs

Medical Board of California Medical Assistants Scope Information

Source: CalOptima Provider FSR/MRR Binder, pages 151–152 • Revised Apr 20, 2026

Medical Advice Over The Phone