Follow-Up Failures Are Risky

Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physicians, and lawsuits related to follow-up failures are becoming more frequent as health care models change, says a 2013 article in American Medical News.

In its Risk Management Guide, the Texas Medical Liability Trust (TMLT) recommends that you create and follow these procedures for follow-ups:

For follow-up on diagnostic testing and results:

  • For patients referred to consultants or any outside source for exams or lab or diagnostic testing, create a tracking system to ensure the patient is seen and you’ve received the results. You may wish to have your staff schedule the consultation and test appointments for the patient, requesting your office be advised if the patient doesn’t keep the appointment. Document the patient’s noncompliance in your medical record.
  • Upon review, initial and date all test results before filing. It then becomes clear that the doctor reviewed all results. As an alternative, you may choose to document your review and the date in the progress notes. Also note in the medical record actions you took on specific results, when applicable. 
  • The person who informs the patient of results can record and initial the date of the call on the report.

For follow-up with patients the day after a diagnostic study:

  • Staff can call the patient to ask how he or she responded to a procedure and determine if there were any adverse outcomes or side effects. 
  • Staff should document the conversation with the patient in the medical record and report any abnormal responses, such as fever, to you, the physician. This follow-up is good for patient relations, as well as risk management.

For follow-up visits: Note in both the medical record and on the superbill when you wish to see a patient back in the office for a follow-up visit. The office staff can schedule the return visit; this system may prevent allegations of failure to follow up.

For follow-up on cancellations and no-shows:

  • Postoperative visits and checkups following office procedures merit particular attention. Documenting calls or letters to the patient demonstrates your efforts to contact the patient should a problem occur later. 
  • Anytime a patient misses an appointment, document that fact and any follow-up action your practice takes. Be sure staff notifies you of the no-show so you can decide if the patient’s condition requires a follow-up call. Always document results of a follow-up call in the medical record, even if it’s “no answer” or “telephone has been disconnected.”
  • If a referring physician’s office scheduled the patient’s appointment, staff should notify that office of the canceled or missed appointment so it can contact the patient and document the patient’s noncompliance in its record. 

You can find sample office procedures for following up with patients in TMA’s Policies and Procedures: A Guide for Medical Offices. TMLT is the only medical professional liability insurance provider created and exclusively endorsed by Texas Medical Association. Availability of TMLT coverage is a TMA member benefit; find more ways TMA can help you manage risk at www.texmed.org/avoidrisk.

Published Aug. 8, 2016 

TMA Practice E-Tips main page

Last Updated On

December 06, 2016

Related Content

Risk Management