Risk Management: 
When Patients Don't Return...
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After If a patient misses a scheduled appointment, every effort should be made to find out why as soon as possible. Where there is an urgent clinical reason, the physician should initiate a phone call to encourage patient follow-up. In those instances where the physician initiates communication, an explanation recommending the patient’s treatment course, its benefits, and risks of not adhering to the proposed treatment should be clearly communicated and documented. Office practices should keep clear, consistent records of missed appointments and follow-up.    In non-urgent situations, the physician should instruct staff, and there should be a notation in the medical record, to call the patient to find out the reason for the missed appointment and to reschedule, being sure to give the time frame; e.g. “call patient to reschedule, must be seen within one week.”  Staff should document their attempts at contacting the patient, what was said to the patient and the patient's response.   While there is no standard number of attempts that should be made, many practices attempt contact three times. A missed appointment letter should also be sent. If patients repeatedly do not return to the office (e.g. three missed appointments), a letter urging patients to follow up should be sent. The “non-adherence” letter gives such patients one last chance to schedule an appointment before assuming that the patient has terminated the relationship. If patients still do not return to the office, then perhaps a formal discharge from the practice is in order. Evidence of patient receipt via certified mail of the correspondence should be retained in the patient’s record.   The missed appointment, non-adherence and discharge letters should state the patient's disease and consequences of not continuing medical/surgical care. If the patient has a condition that requires specific care, the letter should state the care and the consequences of not receiving the care. If the patient has a condition that needs regular follow-up, state the frequency and urgency of the follow-up, and state the consequences of not obtaining the follow-up at the recommended time. All letters should be in clear, reader-friendly language at a 4th grade reading level in order to be understandable and in compliance with limited-English proficiency guidelines.    A tracking process, either through a paper log book or electronic medical record system, provides a comprehensive, consistent process for monitoring of patients. This can be incorporated into the existing tracking method for routine screenings, consultations and diagnostic tests.  A tracking log enables the practice to document that either follow-up was completed, informed refusal has been signed or that “reasonable” attempts to contact the patient have been exercised.   The practice may also track missed/cancelled appointments for specific diagnosis or conditions which the physician determines crucial for patient follow-up. Such circumstances in a surgical office practice may include routine post-operative surgery follow-up. In other practice settings, these would include routine screenings for breast, prostate, and cervical cancer screenings, pediatric immunizations, or diabetes and hypertension monitoring.