Missed and canceled appointments should be documented in the patient's medical record. It is prudent for the healthcare practitioner, or advanced practice provider (APP), to review all missed or canceled appointments. The results of that review should dictate any indicated follow-up measures. All follow-up efforts should be documented in the medical record.
It is prudent for the healthcare practitioner (or APP) to review all missed or canceled appointments to determine what follow-up measures are indicated. Appropriate follow-up may help support continuity of care and ensure that patient needs are evaluated on an individual basis. Patients with more urgent conditions may require additional follow-up based on their clinical circumstances.
To help ensure tracking and follow-up of cancellations and no-shows, document in the medical record when patients:
The medical record should accurately reflect the patient's appointment history and any actions taken by the practice.
The results of the healthcare practitioner’s (or APP’s) review should dictate any indicated follow-up measures. Follow-up efforts may vary depending on the circumstances of the appointment and the patient's condition. Documentation should reflect both the review and any follow-up actions taken.
Patients with more urgent conditions may require more aggressive efforts. The healthcare practitioner’s (or APP’s) review should help determine whether additional communication or follow-up is warranted based on the patient's clinical circumstances.
The same considerations may apply when patients fail to schedule, cancel, or miss appointments with referred specialists. This may be particularly important when referrals involve specialists such as vascular surgery or infectious disease and are necessary for the patient's ongoing care and treatment.
When a referral is clinically important, the healthcare practitioner’s (or APP’s) review should help determine whether additional follow-up efforts are warranted to encourage scheduling or confirm that the patient has been evaluated by the specialist.
Any communication, follow-up efforts, or information received regarding the referral should be documented in the medical record.
For higher risk situations, you may wish to send a certified letter to the patient and keep a copy of the letter and the return receipt. Maintaining documentation of these communications may help demonstrate the practice's efforts to follow up with the patient.
Document all follow-up efforts in the medical record, as accurate documentation helps create a complete record of the practice’s efforts and communications.
Documentation may include:
Accurate documentation helps create a complete record of the practice's efforts and communications.
Missed and canceled appointments should be reviewed and documented consistently. It is prudent for the physician or allied healthcare professional to review all missed or canceled appointments, determine any indicated follow-up measures, and document those efforts in the medical record. Patients with more urgent conditions may require more aggressive follow-up, and a certified letter may be appropriate in some circumstances.
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