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    Denise A. Atwood
    Denise A. Atwood, ESQ., RN, CPHRM

    Once a physician-patient relationship has been established, the physician has a duty to provide care to that patient according to the standard of care and within the scope of the physician’s practice. So what happens when a patient is non-compliant with care or excessively rude to the office staff? 

    The best place to start is by getting to know your patients. Then, when a patient is noncompliant, follow up by meticulously charting the conversations, assessments, recommended treatments and follow-up appointments in the medical record. Knowing your patients will make it easier to implement the following risk mitigation strategies. 

    Risk mitigation strategies

    When dealing with no-show patients, talk to them to determine why they are not showing up to their scheduled appointments. Did they just forget about the appointment? If so, consider implementing reminder postcards or phone calls. Are they unable to find reliable transportation? For many patients that have state-funded insurance (such as Medicaid), it may be a challenge to find dependable transportation. Similarly, it may be too expensive to take a taxi to a doctor’s appointment. In some states, bus passes or taxi vouchers may be provided by the state Medicaid agency to assist patients in getting to and from doctor’s appointments. If your state offers such vouchers, make sure your patients know that they are available.

    If anyone in the office feels threatened by a patient (either verbal or physical threats), implement a protocol to call 911.

    If a patient is not complying with their treatment, ask a few simple questions. Was the patient unable to fill the prescription because it was too expensive? If so, consider an alternative medication or provide samples or see if the drug manufacturer has a prescription program. Was the patient unable to pick up the prescription from the pharmacy due to a lack of reliable transportation? If so, see if appointments and medication refills can be coordinated for the same day. Also, explore mail-order options with the patient.

    If a patient is exhibiting unacceptable, excessively rude or threatening behavior, ask if this is a new behavior for the patient. If so, complete a thorough physical examination and diagnostic testing, as appropriate. Testing may need to include toxicology testing for illicit or prescription drugs. Also, consider a mental health evaluation referral. And if approved by the patient, talk to the person designated on the patient’s HIPAA release form to see when the behavior changes started. As always, objectively document the patient’s behaviors and your clinical assessment and plan.

    Is the patient threatening the staff? Threatening behavior goes beyond rude behavior and includes verbal threats such as wanting to physically harm someone. It may also include physical threats such as slamming office doors or hitting a staff member with a cane. If there are physical threats of violence or harm, staff safety comes first. If anyone in the office feels threatened by a patient (either verbal or physical threats), implement a protocol to call 911.

    Setting limits is also important. For example, if a patient comes into the office and yells at the staff, take the patient aside to let them know that yelling in the office is not acceptable behavior. Reinforce with the patient that your goal, and the goal of the office staff, is to provide safe, quality care to the patient in a therapeutic environment. Remind the patient that if the unacceptable behavior continues, you will consider terminating the physician-patient relationship. Ensure that the discussion and patient education about acceptable behavior is objectively documented in the patient’s medical record.

    If anyone in the office feels threatened by a patient (either verbal or physical threats), implement a protocol to call 911.

    Similarly, you may consider implementing a written agreement with the patient in order to stress the importance of acceptable behavior and to hold the patient accountable for their actions. For example, many pain management physicians use an agreement with their patients in order to stress the importance of care and treatment and to hold the patient accountable in managing their care. Another type of written agreement with the patient may address the importance of complying with prescribed asthma care in order to decrease exacerbations and to, hopefully, circumvent the need for hospitalization. Provide a signed copy to the patient and ensure that a copy is filed or uploaded into the medical record.

    Termination of the physician-patient relationship

    In the event that you have used the aforementioned strategies but the patient is still missing appointments or being abusive, threatening or non-compliant with the prescribed course of treatment, the appropriate thing may be to discharge the patient from care. In that event, you will be best served from a risk perspective if you have been diligent in documentation of appropriate assessments, interventions, referrals and that you provided the patient the opportunity to actively participate in their own care. 

    As with any patient care or treatment, the termination of the physician-patient relationship also must be documented in the patient’s medical record. The medical record should contain objective documentation of threatening or non-compliant behaviors exhibited by the patient at the time the behaviors were observed. 

    Best practice would dictate sending the termination letter via certified mail at least 30 days before the termination from the office or practice. A 30-day notification in writing to the patient is required to assist the patient in transitioning care to another healthcare provider. The office or practice should also offer to send copies of medical records to a new provider to assist in the transition. In the event the patient refuses to accept the certified letter, you can demonstrate that you made a good faith effort to comply with the 30-day notification requirement. 

    Finally, inform the patient’s insurance carrier in writing that the patient has been terminated from the practice so the company may be able to assist in selecting a new provider.

    In developing and maintaining a physician-patient relationship, both the physician and the patient must actively participate. When the relationship is no longer clinically beneficial and cannot be salvaged, then proper termination of that relationship must occur. 

    Example of objective documentation of non-compliant behavior

    “Patient signed a pain management agreement that stated early refills would not be given. Ten days ago the patient received a two-week supply of his pain medication, but he came into the office demanding a prescription refill. As soon as the consultation room became available, I met with the patient to review the pain management agreement, the prescribed medication and the instructions for taking the medication. The patient verbalized understanding and stated that he was concerned he would run out of medications as he is leaving in three days for an out-of-town trip. I confirmed with the patient that we would refill his medication the day before he left for his out-of-town trip.” 

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