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Onboarding Medical Assistants and Office Staff Toolkit

Patient Management

Missed, Re-scheduled, and Cancelled Appointments Primary tabs

The patient’s failure to keep an appointment does not relieve the physician of his/her obligation to notify the patient of the need for follow-up care, abnormal findings or the consequences of failing to obtain care. Physicians should make a reasonable effort to contact the patient who missed a scheduled appointment or test. If the patient cancels the appointment, every effort should be made to reschedule the appointment as soon as possible. All follow-up attempts to contact the patient, and the patient’s stated reasons for missing appointments, should be carefully documented in the medical record.

Although it is reasonable for providers to expect a patient to share in the responsibility for their own care, juries nationwide have placed a significant amount of responsibility for follow up on the provider. It is prudent to document a patient’s failure to follow treatment advice, or keep appointments. If the patient’s failure to follow a mutually agreed upon treatment plan contributes to an injury which in turn results in a malpractice suit, it can usually be introduced as evidence in the doctor's defense. Documentation of patient failed appointments can provide a powerful defense to any lawsuit.

A reliable clinical tracking system is important to identify patients who fail to keep scheduled appointments for tests and consultations with specialists. Whenever possible, schedule referrals and follow-up appointments before patients leave the office. Failure to maintain a reliable clinical tracking system is one of the most frequently cited problems in medical malpractice cases where there is an allegation of delay in diagnosis and/or failure to supervise care.

Maintaining an effective clinical tracking system in your medical office the framework for safe and high quality patient care

Communication among the health care team and coordination of care is critical to improving patient outcomes and reducing professional liability claims.  Whether the practice utilizes an electronic medical record (EMR) or a manual system, reliable follow-up systems are an important factor in providing quality healthcare. Although providers should not be held responsible for the actions taken or not taken by patients, it is reasonable to expect the health care team to advise them of necessary tests, educate them about the risks and benefits of recommended treatments, keep them informed of the results, and provide follow-up as indicated.  This process of reconciliation and follow up is often called “clinical tracking” as it involves “tracking” or following patients throughout the process.

A reliable system of reconciling test results and coordinating care with other health care providers involved in the patient’s care is a fundamental responsibility. When these processes fail, the risk of an adverse outcome is significantly increased.  Even a simple process failure can have significant impact. 

Almost one quarter of medical liability claims originate from a medical office setting. In some medical specialties, such as general and family practice, almost 56% of the claims originate from care provided in the medical office[1].

From 2009 to 2013, among all the healthcare specialties combined, “improper performance” topped the list. This often involves issues pertaining to coordination of care. When a claim was filed, 30% resulted in a payment to the plaintiff. The average amount paid was $316,519.[2] Errors in diagnosis and failure or delay in consultation or referral are among the top reasons for medical liability claims.[3]

Although medical liability is an important issue, the most important reason to implement an effective clinical tracking system is to provide safer care to your patients.

Reconciling test results

Communication among the healthcare team and coordination of care is critical to improving patient outcomes and reducing professional liability claims. Whether the practice utilizes an electronic medical record or a manual system, reliable follow-up systems are important for providing safe care. While providers should not be held responsible for the actions taken or not taken by patients, it is reasonable to expect the healthcare team to advise patients of necessary tests, educate them about the risks and benefits of recommended treatments, keep them informed of the results, and provide follow-up as indicated. Documentation of the process is necessary to demonstrate that the patient was informed.

This involves maintaining reliable processes to follow-up with patients who are undergoing screening or diagnostic testing, as well as those who are referred to other providers for further evaluation and treatment.

Providers are encouraged to design reliable processes that recognize and address opportunities for system failures. In doing so, the practice will be better equipped to improve patient safety and reduce the risk of a professional liability claim. A well-designed tracking system includes:

  • a patient follow-up process
  • a test tracking management system
  • a referral management system
  • a mechanism for documenting informed agreement and/or refusal

A test results management system identifies all essential screening and diagnostic tests ordered and performed (within or outside the office.) Tests performed outside the office tend to be the most problematic to track.

Essential tests include the following:

  • all tests ordered during the work-up of a critical or acute problem.
  • tests ordered where subsequent follow-up is essential, and the risk for not following-up is high.
  • tests ordered to monitor medication levels with known adverse effects such as INR levels for patients on anticoagulation therapy. Other examples include diuretics, cholesterol-lowering drugs and certain antibiotics.
  • tests ordered in which the specimen (blood, pathology, etc.) is obtained in the office but sent elsewhere for testing.

Components of a well-designed test management system include:

  • a process where the patient is involved in the identification process prior to any specimen collection and using two forms of patient identification, excluding the room number.
  • a process for tracking pending lab results that ensures their receipt by the practice as well as a method for identifying test results that are not received.
  • a mechanism to ensure that test results are reviewed and acknowledged by the provider.
  • a process for patient notification of test results and for such notification being documented in the medical record.
  • a process that ensures follow-up of any additional testing/monitoring required/needed.

Maintaining a reliable and effective clinical tracking system requires teamwork and an ongoing willingness to monitor performance and process issues. Because of its significance in reducing the risk of adverse patient outcomes and professional liability risks, practices are advised to routinely evaluate the effectiveness of its systems, identify potential system failures, and address any opportunities for improvement. Maintaining an effective clinical tracking system is the most labor intensive processes within a medical office, yet one that can most effectively ensure quality patient care.

Referrals and consultations

There will be times when some patient’s clinical problems may be beyond a physician’s expertise or specialty, and the use of a consultant is warranted. Below are listed some of the most common situations when a consultation is needed.

  • It is advisable for a physician to obtain a consult when he/she is uncertain about the diagnosis or treatment, especially when the patient’s problem is outside of the physician’s specialty or when the patient’s particular condition is ordinarily treated by another specialty or subspecialty.
  • If an adverse outcome is anticipated, seek the advice of a second physician.
  • If the patient or family requests a second opinion, get a consultation.
  • Use a consultant if an alternative or combined therapy involving another specialty can be considered.
  • When the handling of a case is questioned, obtain a consultation.
  • Obtain a consultation when the patient does not respond to treatment as expected.

After a physician decides a consultation is needed, it is suggested that the physician take certain measures to ensure communication between the providers. The following guidelines are recommended:

  • Document the reason for the consultation in the patient’s chart.
  • Explain to the patient the need for and purpose of the consultation.
  • Communicate orally with the consultant, especially in serious and urgent cases.
  • Provide the consultant with a complete history and records of the case along with an opinion.
  • Document the rationale for the treatment if it is different from the consultant’s recommendations.
  • Ensure there is a clear understanding among the patient, primary physician and consulting physician, as to who is responsible for the patient’s continued care.
  • Track to make sure the patient keeps the consultative visit.

The consultant also has communication responsibilities to the patient and physician. These responsibilities are listed below.

  • Inform the responsible physician and the patient of complications that might arise from procedures the consultant carries out.
  • Communicate the findings and recommendations to the referring physician and patient in a timely manner.
  • Provide a complete copy of the consultant’s report to the referring physician.
  • Notify the referring physician if a patient does not keep an appointment with you, the consultant. If a referring physician doesn’t receive correspondence from the consultant within a designated time frame, he/she should check with the patient first to determine patient compliance. Document the conversation with the patient, and proceed according to your office policy or system protocols. Usually, Risk Management recommends up to three separate reminders per patient in high risk situations and/or when providers are in diagnostic pursuit.

Recommended Reading: NCQA Patient-Centered Medical Home NCQA Standards Workshop 2011, PMCH 5B Referral Tracking and Follow-Up. pp. 20-23 Accessed 8/20/2012

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.