PHYSICIANS' RECIPROCAL INSURERS
Risk Management Department
Loss Prevention Technique © 1992

January - March 1992
(Volume VI, Number 1)

Physicians often encounter patients for whom further care or clinical investigation is necessary. In some of these instances, the patient is not seen nor heard from within the prescribed time frame and may never be heard from at all. The physician may not remember anything concerning the patient until (s)he receives notice of a law suit, which alleges that the patient suffered an untoward outcome due to the physician's lack of follow-up on previously recommended care. These are the patients we refer to as being "lost to follow-up" or having "fallen through the cracks".

One of the most damaging aspects of these cases, is the appearance that the physician was not aware of what was occurring with the patient and, therefore, not managing his/her care. A patient can become "lost to follow-up" in various ways. The following is a review of where patients usually get lost and some steps that may be taken by the practice to help prevent these occurrences.

PATIENTS ADVISED TO RETURN IN SHORT TERM
The physician will often advise a patient that (s)he is to return to the office within a few days or weeks. In order to help ensure that this follow-up does indeed occur, these patients should be given an appointment prior to their leaving the office.

This serves at least two important functions: the importance of the follow-up visit is further enforced with the patient and also, the scheduled appointment serves as a "tickler" system to the physician, in the event that the patient does not come in for that visit. Of course, the missed appointment will only trigger further action if your practice has a system to contact patients who miss important appointments.

In practices where patients are not seen by appointment, an alternate plan such as a log or diary system, must be in place so that these patients are not lost to follow-up if they fail to appear for care in the recommended time frame.

PATIENTS ADVISED TO RETURN IN LONG TERM
Patients are often advised to return in several months for an important follow-up visit. In practices where this is done routinely and where those visits are considered significant to the care of the patient, it is prudent to establish a recall system.

With such a system the patient may be sent a card or note reminding him/her that an appointment is to be scheduled. Copies of such correspondence should be maintained in the patient's file and should there be no response from the patient, the physician can decide, based upon the urgency of the situation, whether (s)he wants to take further steps to contact that patient.

In the event of an untoward outcome and a subsequent law suit, the physician's system and the evidence of his/her efforts to bring the patient into compliance, will certainly be supportive of the physician's defense.

PATIENTS WHO POSTPONE CARE
The physician will sometimes encounter patients who need a surgical procedure or diagnostic testing, but who wish to postpone it or postpone making the decision probably for personal reasons. If the physician believes that such a delay will not have a negative impact upon the patient care, the physician and the patient should agree upon a time frame within which the patient will contact the physician. This discussion, including the agreed-upon time frame, should be documented in the patient's chart. However, if these patients do not contact the physician within the agreed upon time frame, the physician should contact the patient.

In order to keep track of these patients, the physician's office should maintain a list or some other monitoring system so that these patients may be readily identified and contacted.

All efforts to contact the patient and the gist of the conversations) with the patient must be documented. If the patient refuses treatment, then the situation should be handled as recommended in PRI's Loss Prevention Technique, Refusal of Treatment, (April/June 1989).

Below is a list of our Loss-Prevention Techniques:

Telephone Matters | Patient Relations | Test Results and Follow-up Monitoring Patients | Patient Follow-up
Guidelines for Comprehensive Office Chart
Emergency Prepardness | Developing Telephone Protocols
Medical Office Personnel | Medication Matters
Issues in Physician Coverage
Discounting the Doctor/Patient Relationship