Why is it important to document missed appointment in the patients medical record?

MLMIC Risk Management Tip #5 addresses medical professional liability risks related to “Follow-up of Missed or Cancelled Appointments.”

The Risk

A missed or cancelled appointment and the failure to follow up with or contact the patient may result in a serious delay in diagnosis or treatment. A well-defined process that includes provider notification and follow-up procedures in this situation will help ensure continuity of care and enhance patient safety.

Recommendations

1. Develop a process for the follow-up of patients who have missed or cancelled appointments.
2. Physicians should be notified of all missed or cancelled appointments on a daily basis.
3. The physician should assess the clinical importance of the appointment, the severity of the patient’s medical condition, and the risk(s) associated with the missed or cancelled appointment to determine appropriate follow up.
4. A reminder telephone call from the office staff may suffice for patients at minimal risk. The telephone call and the content of the message or conversation should be documented in the patient’s record.
5. A telephone call from the physician may be indicated for patients at higher risk. The physician should emphasize the importance of follow-up care and the risks inherent in failing to comply. This conversation should also be documented in the medical record.
6. If there is no response from the patient or the patient develops a pattern of not keeping or missing appointments, a letter with a certificate of mailing should be sent to the patient to advise him/her of the risk of non-compliance. A copy of the letter should be maintained in the patient’s medical record.
7. All efforts to contact the patient, either by telephone or in writing, should be documented in the medical record. This provides evidence that the patient was made aware of the importance of continuous medical care.
8. Educate your staff regarding patient follow-up processes in your practice. Consider conducting periodic record reviews to evaluate the effectiveness of the established processes for patient follow-up.
9. Continued failure of a patient to keep appointments may be deemed non-compliance with treatment. Consideration should be given to discharging the patient from your practice. The attorneys at Fager Amsler Keller & Schoppmann, LLP are available to assist you in determining how and when to properly discontinue a physician-patient relationship due to patient noncompliance.

This MLMIC Risk Management Tip is available here as a PDF: “Follow-up of Missed or Cancelled Appointments.”