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Patient tracking and follow up: What you don’t know can hurt you

By Laurette Salzman, MBA, CPHRM, ProAssurance Senior Risk Resource Advisor

Lapses in patient care, including follow up, can lead to dire consequences beyond those to patient well-being. Substantial malpractice settlements and verdicts have been paid as a result of “lost” diagnostic reports and physicians’ failure to review and follow up.

Patients who miss or cancel appointments risk undetected and untreated medical conditions, threatening continuity of care. If the patient later experiences an illness or injury, he or she may hold you responsible. The best way to prevent such lapses—and the corresponding malpractice allegations they create—is to develop written policies and procedures. The goal is to effectively track lab and diagnostic tests, as well as missed appointments and referrals.

Lab and Diagnostic Tests
Establish a tracking system that documents and follows patients referred for diagnostic imaging or laboratory testing. An effective system will verify the following:

  • test is performed.
  • results are reported to the office.
  • physician reviews the results.
  • physician communicates the results to the patient.
  • results are properly acted upon.

 
It is important the physician or allied health professional (AHP) review, authenticate and date all diagnostic test results as soon as they are available—before filing. When test results are abnormal, it is important to let the patient know both the results and the need for follow up. If the patient does not follow through as advised, it is prudent to make—and document—repeated efforts to encourage the patient’s return.

Cancellations and No-Shows
Tracking missed or cancelled appointments will help you improve patient care and reduce liability risk. When patients miss or cancel appointments, attempt to reschedule and document both the reason for cancellation and each of your efforts to reschedule.

We suggest the AHP review all missed or cancelled appointments and discuss them with the physician to determine if follow up is necessary. More aggressive follow up may be necessary for patients with urgent conditions. Document all such efforts in the medical record.

Consultations/Referrals
Plan to develop an effective system to identify and track patients who are scheduled for referrals and consultations. Document in the patient’s medical record all recommendations that a patient see a specialist for consultation or continued care. Include any letters or other communications between physicians in the medical record.

Types of Tracking Systems
Tracking systems do not have to be complex or expensive; they just have to work. Many medical practices use simple and inexpensive methods, such as logbooks. Others utilize tracking functions provided in their electronic medical records system. Whatever tracking method you choose, be sure to follow up on laboratory and diagnostic tests, cancellations, no-shows, and consultations.

Copyright ©2015 ProAssurance Corporation. This article is reproduced with permission.

This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct.

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