Risk Management

No-Shows Can Spell Trouble for Attending Ophthalmologists

By Oksana Mensheha, MD

Argus, June, 1992

A patient’s failure to keep an appointment or to follow through on a referral to a specialist can expose the attending physician to liability if a complication or injury occurs because the patient failed to obtain treatment. The ophthalmologist should document missed or canceled appointments in the patient’s chart and, when appropriate, follow up with a phone call. Patients may simply forget routine visits, or they may be dissatisfied with the physician, and a no-show may be the first sign of a potential claim.

A case from the OMIC files illustrates the importance of the attending ophthalmologist communicating to the patient the potential seriousness of an eye problem and the need to follow through on a referral to a specialist.

A patient complaining of double vision was seen three times over a two-month period. At the third visit, proptosis of the right eye was noted. Three months later the patient returned with the same complaint. The ophthalmologist made a note in the chart to consider a neurological work-up and told the patient to return if there was no improvement. The patient never returned to this ophthalmologist, but a subsequent treating ophthalmologist obtained a CAT scan, which revealed a retrobulbar mass. Although the mass was removed, the patient sustained a residual defect and sued the first ophthalmologist. The case was settled for more than $100,000.

Sometimes, patients deny the seriousness of their problem; then, when the full problem unfolds and denial is no longer possible, they turn their frustration and anger on the physician. A young man was treated for “red eye.” He then missed his next two scheduled appointments and did not return until three months later when he presented with an overwhelming herpetic infection. The infection was successfully treated, but if the ophthalmologist had contacted the man when he missed his first appointment and treated him sooner, a potential claim would have been avoided.

In these cases, significant problems stemmed both from the ophthalmologist’s failure to communicate the seriousness of the problem to the patient and from the patient’s failure to return for scheduled appointments. This breakdown of mutual responsibility often results in lawsuits against physicians alleging failure to provide appropriate and timely referral or follow-up care. Although patients clearly bear some responsibility for follow-up care, especially when the need for such care or the patient’s role in seeking follow-up care has been explained to the patient, patient responsibility alone does not provide the ophthalmologist with an ironclad legal defense if a malpractice suit ensues.

Ophthalmologists would be well advised to consider the following risk management guidelines when dealing with patients who fail to follow through on treatment:

Listen to and document the patient’s complaints and symptoms.

Communicate to the patient all your concerns about the patient’s problem as well as your plans for further treatment.

Develop a system of reminding patients to follow through on referrals to subspecialists and document in the patient’s chart that you have done so.

Personally review all test results and reports from consulting physicians before they are filed in the patient’s record, and be sure that the patient has been notified of these results.

Document all missed appointments and have these charts placed on your desk at the end of the day for review. When appropriate, contact patients to reschedule. Do not erase or otherwise obliterate cancellations and no-shows in the daily log. If the patient has been referred, the referring physician should be notified of any missed appointments.