Patient Non-Compliance or Failure to Attend Appointment

Physicians should document all instances of a patient
refusing an examination. Most physicians have had an
experience where a patient has refused to have an
examination or a specific portion of an examination,
or asked to defer the examination to a later date. It is
essential that physicians document all advice, tests or
treatments that are refused or deferred by the patient
to ensure that anyone who reads the medical record
will receive an accurate depiction of the treatment that
the patient has received, and will gain an understanding
of the treatment decisions the patient has made.
Where treatment has been refused or deferred, the
medical record should also indicate the reason, if any,
given by the patient for declining the advice and treatment
recommendations of the physician, as this information
may be important for the future care of the
patient.
The medical record should also note when a scheduled
appointment is missed by a patient.

Telephone Conversations and E-Mails
Ideally, all telephone calls would be recorded in the
patient’s chart. It is strongly recommended that telephone
calls dealing with matters of significant clinical
impact that are made to or received from the patient
be documented. The documentation should include
the date and time of the call, significant information
and advice provided. Records should also indicate any
prescriptions or repeats authorized over the telephone.
The CMPA emphasizes the importance of documenting
phone calls as evidenced by its development of a
“Patient Telephone Call Record,” available free-ofcharge
to members. This note-sized sheet has a selfadhesive
portion that allows the physician to affix the
completed note into the patient’s medical record.
There are a few good reasons for including phone calls
in the medical record because they:
• Will assist in providing better continuity of care;
• Could provide significant evidence in lawsuits, hearings
or inquests when provision of patient care
might be in question;
• Serve as fundamental components of external
reviews relating to quality of care, and inquiries such
as those made by the Coroner’s Office, etc.
Records of e-mails to and from patients should be
treated in the same way as records of telephone calls.
Where possible, it is advisable to copy all correspondence
for the chart, particularly those dealing with
matters of significant clinical impact.