Which of the following is the most appropriate action documenting patient no shows in the appointments schedule?

Medical practices are often challenged with how to handle a missed appointment during which follow-up care or treatment was to be provided. It is important that the practice have a procedure to ensure that no-shows and cancellations are communicated to the treating provider and any actions taken are documented in the medical record.

Depending on the patient’s diagnosis and/or reason for the appointment, the treating provider may instruct an assigned staff member to follow-up missed appointments either verbally or by way of a “missed appointment letter.” Generally, the efforts required to contact the patient are commensurate with the patient’s medical condition and potential consequences of missed treatment.

When notifying the treating provider of a missed appointment, staff should include the reason for the visit. Depending on the patient’s diagnosis and/or reason for the appointment, the treating provider may instruct that the patient be contacted and informed of the need for the appointment to be rescheduled and kept. Instructions should include the time frame (e.g., “call patient to reschedule, should be seen within 7-10 days”).

If a patient is at minimal risk (e.g. a well checkup), no action may be required or a single phone call or letter outlining the consequences of failure to receive needed treatment in a timely manner may be sufficient. It may be necessary to warn the patient of possible discharge from the medical practice for repeated missed appointments.

For patients at moderate risk, such as those who need ongoing monitoring or treatment, a more concerted effort may be required. Usually two documented phone calls and a certified letter outlining the consequences of failure to receive needed treatment in a timely manner should be adequate.

If the missed appointment is for the purpose of notifying the patient of abnormal test results requiring further treatment, failure to follow-up on a missed appointment could lead to a delay in diagnosis if the patient is not notified and treatment does not ensue. Generally, the reasonableness of the follow-up effort will depend on the clinical importance of the test results, the severity of the patient’s medical condition and the risk associated with failing to notify the patient of the results.

All efforts to educate the patient and complete the follow-up should always be documented in the medical record. If letters are sent, they should be in clear, reader-friendly language at a fourth grade reading level in order to be understandable and in compliance with Limited-English Proficiency Guidelines. If the letter is returned undeliverable, verify that the address corresponds with the address given by the patient and if the post office provides a new address, resend the letter to the new address and note this in the medical record. If a letter is returned because delivery was refused by the patient, resend the letter to the same address using first class regular mail.

As with all patient communication, staff should document the date and time of the call or place a copy of the missed appointment letter in the patient’s medical record.

If a patient repeatedly does not return to the office, after appropriate contact attempts have been made, the treating provider may take steps to discharge the patient from the medical practice. Please consult an SVMIC claims attorney for assistance by calling 800-342-2239 or 615-377-1999.

• Home
• Improve Your Practice
• Operations
• Appointment systems

• Physical Practice
• Staffing
• Communications
• Operations
  • Policy and procedure manuals
  • How to develop and use manuals
  • Change management
  • Appointment systems
  • Medical record management
  • Telehealth
  • Cloud computing
  • Emergency procedures
  • Specimen collection and management
• Time

For practice managers, having a flexible and well-designed appointment system is vital to ensure your practice runs efficiently to monitor patient attendance and support effective time management, and inform patient triage and staff requirements. The appointment system underpins many of the practice’s operations and should reflect the overall practice policy as well as the schedule requirements of each practitioner.

General overview

Informed patients

As a practice manager, make sure you inform new patients about your appointment policy and procedures. They need to know what your expectations are regarding cancellation of appointments, whether they will be notified if there are delays, and what “reasonable access” actually means. This information can be presented as part of the information included in the form of a practice brochure and could include:

• policy on cancellations: patients need to be notified of cancellation conditions (e.g. cancellation charges, limit on number of cancellations, etc.)
• what happens when patients do not present for scheduled appointments
• what happens in the event of delays due to the practitioner’s attendance at hospitals e.g. procedures, confinements (for obstetric patients) or the emergency care of patients
• advice about whether patients should phone before a scheduled appointment (e.g. 30 – 40 minutes) to check the schedule statuses; alternatively you may use SMS to advise patients of any delays. Times will vary according to type of practice and generally speaking, every patient attending general practice would not telephone beforehand.
• where patients are delayed at the practice waiting for their appointment, remember to keep them informed, check on them, offer refreshment
• emergency arrangements
• any practice appointment reminder/confirmation processes, e.g. SMS
• online appointment availability and procedures
• variable lengths of consultations for varying treatments.

For particular specialist practices there may be unique aspects to consider.

e.g.: For obstetricians, the following points could be considered in the appointment
scheduling:

• frequency of ante-natal visits
• specialist availability – will be required to leave rooms on occasions to deliver infants and attend other emergencies
• planning extended or annual holidays well in advance to manage anticipated deliveries
• advising patients early in their confinement that the specialist may not be available at the expected delivery time.

For proceduralists:

• Follow-up appointments should be made at the time of booking the procedure or on discharge.

Triage

In the development of your appointment policy and protocols, you will also need to consider triage and delegations. A triage system allows identification of patients who require priority access to the practitioner/treatment due to potentially serious/urgent presentations. ( see “POPGUNS” resource )

A particular skill required by front desk staff is the ability to prioritise, or triage patients – whether this is by patient presentation at the practice or by referral from another practitioner by phone, so that the sickest can be treated first. Examples:

Your protocol may be that all calls from another medical practitioner about a referral are forwarded directly to the practitioner to determine urgency and scheduling.

In a general practice, the staff may be delegated the task of determining the urgency of ‘fit-in’ appointments. If this is the case, the protocol would clearly state what complaints/symptoms described by the patient are immediately referred to the general practitioner or practice nurse (if employed) and when staff are expected to call for an ambulance.

General practices that employ a practice nurse may decide to transfer all callers with concerns immediately to the nurse for immediate triaging.

When patients present, they may also be triaged and, as appropriate, directed immediately to the practice nurse/clinically trained staff member and taken to a treatment room.

In larger practices it may be that there is a nominated GP rostered to attend to urgent/walk-in patients on a particular day.

Appointment systems should enable prioritising of appointments, either labelling or colour-coding ‘urgent’ appointments so practitioners can easily determine the status of patients in the waiting room.

If your expectations of your staff with regards to triage do not match their qualifications and/or training, you are endangering your patients and leaving your staff (and hence yourself) exposed.

The art of appointment scheduling

Time management

Ideally, an appointment system should include the following features to ensure the best time management:

• patient name and identifier (file identifier/address/phone/date of birth)
• date of appointment
• time of appointment
• flexible length of appointment
• practitioner name
• patient confidentiality
• be easy to use and linked to your practice management software
• be easy to generate reports, such as:
• waiting time (how long is the patient kept waiting after the scheduled appointment time?)
• number of patients seen by session/day/week/month
• ability to send SMS reminders from the appointment system
• ability to record confirmation of attendance received from patients
• ability to record relevant comments regarding the appointment e.g. patient birthday
• allows for integration with online appointment booking programs
• record of cancelled appointments
• capacity to change appointment times, whilst recording changes (audit trail)
• record of “no shows”
• incorporate an effective triage system (patients requesting an appointment should always be asked if the appointment is urgent, especially prior to being put on hold)
• utilise a back-up/restore system to maintain permanent records and to assist in restoration if the computer systems fail
• printing of appointment lists daily, as a measure against things such as power failure or loss of access to computers

Schedule your consultation lengths to enable adequate time to:

• review previous patient notes or referral letters
• obtain a history
• conduct an assessment
• discuss the management plan with the patient
• document clinical findings by the practitioner
• ensure post-operative appointments have been scheduled at time of discharge
• schedule breaks to enable doctor to attend to phone calls, paperwork and documentation
• schedule adequate rest breaks.

Non-attendance of patients

A patient’s non-attendance or cancellation of a review appointment may be an indication of a dissatisfied patient but also can require clinical follow-up. When a patient does not present for a scheduled appointment, or leaves before being seen by medical staff, the practitioner should be notified. With existing patients, document why the appointment has been cancelled and what further action, if any, should or has been taken.

If you have concerns about patient compliance, a letter could be sent to the patient or to the referring practitioner and a copy of this letter kept on the patient’s file. If the condition is serious, the letter should be sent to the patient by registered post.

Recording and monitoring patient attendance

Use the appointment system for:

• Following patients who do not attend or cancel appointments and who require medical follow-up; you can create a specific appointment code that recognises “urgent/clinical recall/urgent follow-up” status and this provides a visual prompt should that patient fail to attend.
• Monitoring patients where the doctor has particular concern about their health status
• Managing patients who have suffered an unexpected or adverse outcome.

To maximise quality patient outcomes, it is important that the appointment system alerts the practitioner to patient compliance and supports the recall and monitoring requirements.

The practitioner should be made aware of all “no shows” and cancellations so that a decision can be made if further action is required.

Improve your practice

Computerised appointment systems

If a computerised appointment system is utilised, this will often be linked to the practitioner’s desk where non-attendance and cancellations are retained on the daily scheduling screen.

For computerised appointment systems, you should ensure clear protocol for staff regarding communication with practitioners about cancellations or rescheduled appointments, as these will disappear off the day’s appointment list as they are cancelled or moved.

Your practice protocol might be for staff to add cancelled or rescheduled appointments back onto the bottom of the day’s appointment list with a notation. This would mean practitioners could easily review the changes and make a decision as to whether follow-up action is required.

Paper-based appointment systems

For paper-based appointment systems, this can be supported by the following:

• Record at the bottom of each appointment page the names of the patients who cancelled or did not attend; the reason for cancellation/non-attendance and the rescheduled date, if applicable. This can be photocopied and presented to the practitioner.
• Record the above details on a daily/weekly list and provide this to the doctor at the end of the session/day for action and its documentation. If documenting action on a day list, ensure these lists are archived as a record of patient compliance.
• For existing patients, document in the patient’s record why the appointment has been cancelled and what further action should, or has been taken. A cancellation/DNA ‘stamp’ could be used – the file can then be forwarded to the doctor for their ‘decision’ and signature.
• If you have recalled a patient for a scheduled appointment an ‘R’ (recall) placed against their name will alert the staff and the practitioner if this patient cancels the appointment or does not arrive for the scheduled appointment.

Next page

• What is a medical record?
• Who owns the medical record?
• How should medical records be stored?
• How long should medical records be kept?
• Disposal of paper-based medical records
• Keeping medical records secure
• Access to medical records
• eHealth records
• Improve your practice
• References

Which of the following is an action that would motivate a patient to not miss an appointment?

Which of the following is the most appropriate action when a patient telephones with symptoms of an acute illness?

Which is the best action for scheduling a physician who is consistently late for appointments?

What is the best approach for handling the cancellation of an appointment by a patient?