As every patient visit concludes with a documented office visit encounter, the visit note should include when the patient is advised to return. The suggested documented return visit (i.e. f/u in 2 weeks, 1 month) should be documented in the Action or Plan portion of the progress notes and the patient instructed to make a follow-up appointment before leaving the office. At the end of each visit, the physician should confirm that the patient understands the rationale for the recommended return visit or treatments, the presumptive diagnosis, next steps for follow-up, and signs or symptoms to watch for.
Following up with a patient is important and should be tailored to the patient’s symptoms and the progression of the disease. Following up gives the practitioner an opportunity to address unresolved concerns, respond to symptoms that have worsen or do not respond to treatment, or formulate a differential diagnosis enabling appropriate testing. Clinical conditions can be difficult to diagnose during a single patient encounter. There may not be enough time to address multiple problems during a visit. Providing return visits and following up may potentially identify a serious unsuspected medical condition.
Continuity of care can be compromised when more than one provider is involved in a patient’s care. This underlines the importance of clear communication between providers and across settings. A patient injury resulting from the patient’s own failure to return for a follow-up appointment could help defend against a claim of negligence or delay in treatment or diagnosis. When no specific follow-up is required, a “return if any problems” (specific problems can be noted if needed) or just f/u PRN in the note means the doctor gave the patient the responsibility to decide when to return.
Going a step further, the office should have a system in place to follow-up on patients that do not schedule their next appointment before leaving the office such as a simple tickler file that reminds staff to call the patient in the next day or two to schedule the next patient visit.
Staff also should document no-shows and/or canceled appointments in the medical record of patients who consistently miss or frequently cancel appointments. It is a good practice to develop a system to notify the provider of these instances so the provider can decide whether a follow-up phone call to reschedule should be made.
Many factors can contribute to non-adherence such as communication issues, a patient’s level of comfort with their treatment plan, or their ability to afford a treatment. It may take an additional effort on your part to address unresolved health complaints by non-adherent patients to address serious conditions.
Having this information documented in the patient medical record will show the provider is managing the patient's care and will undoubtedly help forego unnecessary medical liability claims. Careful history-taking and documentation are crucial.
Diana Douglas, CPHRM
Vice President, Risk Management
This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.