Patients who fail to attend an appointment


Summary:
It’s a busy morning in the clinic. A patient who had a 10.30am appointment does not attend. What are the possible implications if neither the clinician nor practice staff take any action regarding the missed appointment? For repeat appointments, the practice staff will be in a better position to identify cases where action is essential and in the patient’s best interests.

They may be able to triage the situation into various categories:

  1. non-urgent
    for example, a diving medical or vaccination
  2. non-urgent but needs follow-up
    for example,to discuss test results of no great significance
  3. urgent
    for example,significant test results
  4. very urgent
    for example,concern about the patient’s immediate well-being, for example an elderly patient who lives alone and always attends.

The situation is more complicated if the patient has never been seen before. This is especially so for specialist practices. Specialists have often already received test results or other information indicating a degree of clinical seriousness. A common example is an abnormal pap smear, where the patient fails to attend. Under this circumstance it is essential for the specialist to let the referring GP know of the non-attendance.

Duty of care

You have a duty to exercise reasonable care and skill in the treatment of patients. Administrative staff also have an obligation to exercise reasonable care. This duty extends to the examination, diagnosis and treatment of the patient, the provision of information and follow-up.

Case law

Case law regarding patient follow-up has centered on follow-up of tests, and suggests that once you have undertaken tests or recommended a procedure or test, then – for the duration of your relationship with the patient – you have a duty to:

  • take reasonable steps to inform the patient of the importance of the tests and the possible clinical possibilities if the tests are not undertaken
  • take reasonable steps to remind the patient to have the recommended tests or procedures. For example, this may involve
  • setting a computer reminder to contact the patient if a referral report or test result is not received by a certain date.
  • follow up the results of tests he or she has recommended and the patient has undergone
  • advise the patient of the results of those tests.

There is also case law outlining the responsibility of a referring doctor to follow up referrals to specialists.

Many practitioners feel that the onus of responsibility on them is too great and that the courts have inappropriately shifted patients’ responsibilities to the practitioner. This may be a genuine feeling but it has limited sympathy in law. It is important to note, however, that the principles underpinning the case law in this area have been captured in College standards and Australian Medical Association (AMA) position statements.

RACGP standards

The RACGP [Royal Australian College of General Practitioners] Standards for General Practices outline a practice’s responsibilities for follow-up of clinically significant tests and results. Clinically significant refers to:

  • the probability the patient will be harmed if adequate follow-up does not occur
  • the likely seriousness of the harm
  • the burden of taking steps to avoid the risk of harm. 

AMA position on patient attendance at consultations

The AMA position statement on patient follow-up and tracking, in section 2.3, Patient Follow-Up, Recall and Reminder Systems, includes the following recommendations for care:

  • Practitioners may request patients to return for a consultation and should clearly inform the patient why the follow-up consultation is recommended and the potential consequences of not proceeding.
  • Follow-up arrangements, such as the means of contact between the practitioner and patient, should be clarified and documented during the consultation at which follow-up is recommended.
  • As part of the healthcare partnership, patients who reject their practitioner’s advice to return or to contact the practitioner following a referral need to be aware of their responsibility for that decision. However, if a practitioner is advised of a clinically significant abnormal result or diagnosis, the practitioner has an ethical obligation to make reasonable attempts to ensure the patient becomes informed and understands the significance of such results or diagnosis.

Systems within your practice

Most GPs now use some form of electronic medical record and practice management system. This has enabled very convenient and reliable recording of patients’ appointments and easy identification of non-attenders. It has also enabled staff to look regularly at a list of outstanding recalls. Unfortunately, errors still occur because of human factors in understanding and using the software.

Strategies to manage this risk include:

  • ensuring appointments are ‘tagged’ or ‘identified’ as a follow-up or recall appointment when the patient books the appointment
  • developing a list of patients who fail to attend their appointment or who cancel and fail to reschedule
  • the practitioner reviewing the list of non-attending patients as soon as practicable (preferably during or at the end of that session), and making a decision about the follow-up required. In many computerised practices, a different colour is assigned to bookings for recall patients to enable staff to recognise non-attending recall patients.
  • on reviewing the list, the practitioner decides on the clinical significance of the circumstances of the particular patient’s case. Where action is necessary, the clinical significance of the case may suggest a phone call is appropriate and adequate, or two or three phone calls at different times of the day and a letter to the last known address by person-to-person registered mail. Letters should include information about the potential significance of not attending. Where it may be a matter of life and death and your attempts to contact the patient have failed, it may be reasonable to ask the police or ambulance to help find the person. Centrelink may also assist. All attempts to contact patients should be documented.
  • making orientation to all new practice members, including practitioners, on the procedure for ‘failure to attend’ an imperative. Annual review, with input from the entire practice team, helps ensure compliance.

Clinically significant referrals should be systematically tracked. When a letter or phone call is received from the specialist, the referral is taken off the list. The list can then be periodically reviewed for any outstanding referrals.

Communicating the need for follow-up

As the practitioner, you have an obligation to fully explain why follow-up is required. Patients may not understand the significance of the need to see another practitioner or have more tests and may dismiss the request. You must make it clear why something must occur, using an interpreter as necessary.

Consider approaching this part of the consultation in the same way as a consent process. By informing the patient of the need for the tests, your concerns, the reasons for and the risks associated with not attending the referral or a follow-up appointment, you pass the responsibility and the choice to the patient. This process and documenting the advice given (for example, explained need for tests to rule out ‘X’. Come back for results in (two weeks) will assist in defending an allegation of the failure to follow up.

Documentation

All attempts at follow-up need to be documented in the patient’s medical record. Documentation of phone calls should include the date and time of the call, the name of the person who made the call, any message given and any action taken.

Copies of letters sent should be included in the record, and notations made where letters are sent by registered mail. Missed appointments should also be clearly documented in the records. The appointments system should allow a permanent record of all cancellations and failures to attend.

Proactive systems can help prevent missed appointments:

  • All patients have their contact details and changes to their preferred method of communication checked at every appointment. When writing an investigation request, or a referral, ask the patient to confirm their current address.
  • When patients make an appointment, ask them to phone if they won’t be able to attend.
  • Practice signage and/or newsletters remind patients to phone if they can’t attend an appointment.
  • Some practices send SMS reminders the day before an appointment, with patient consent.
  • The practice may want to consider a system to manage patients who repeatedly miss appointments.
  • Practices can charge for missed appointments, but make sure patients are aware of this.