What should be documented in a patient's medical notes if they leave before a scheduled re-evaluation?

Documentation for Patients Who Leave Before Re-evaluation

When a patient leaves before a scheduled re-evaluation, medical documentation should clearly state that the patient left before completing care, along with specific details about their clinical status at last assessment and attempts made to contact them.

Essential Documentation Elements

1. Objective Clinical Status at Last Assessment

• Document the patient's most recent vital signs, physical examination findings, and mental status 1
• Include any laboratory or diagnostic test results that were available 1
• Record the patient's symptoms and condition at the time they were last evaluated 2

2. Classification of Departure Type

• Clearly distinguish between:
  • Left without being seen (LWBS): Patient left before initial provider evaluation 3
  • Left against medical advice (LAMA): Patient left after evaluation but against provider recommendation 3
  • Eloped: Patient left during treatment without notifying staff 4

3. Documentation of Attempts to Prevent Departure

• Record any discussions with the patient about the importance of completing evaluation 2
• Document any attempts to address patient concerns (wait times, expectations, etc.) 4
• Note if the patient was informed of risks associated with leaving before completing care 5

4. Follow-up Plan and Attempts

• Document any follow-up instructions provided to the patient before departure 2
• Record any attempts to contact the patient after they left (phone calls, messages) 5
• Note any scheduled follow-up appointments or referrals made 2

Special Considerations

Risk Assessment Documentation

• Document any concerning symptoms or abnormal findings from the initial evaluation 6
• Note the patient's triage category or acuity level at presentation 3
• Record any high-risk factors that would warrant urgent re-evaluation 2

Medical Decision-Making

• Document your clinical impression based on available information 2
• Note any differential diagnoses being considered at the time of departure 6
• Record any treatments that were initiated or planned but not completed 3

Medico-Legal Considerations

• Avoid subjective judgments about the patient's decision to leave 1
• Document factual, observable behaviors rather than assumptions 1
• Record the exact time the patient was discovered to have left 5

Documentation Template Example

Patient was seen at [time] for [chief complaint]. Initial assessment showed [vital signs, exam findings]. 
[Tests/interventions] were performed with [results if available].

At [time], it was discovered that patient had left the facility before scheduled re-evaluation.
Last known status: [vital signs, symptoms, mental status]
Outstanding concerns: [list any concerning symptoms or test results]

Attempts to contact patient: [document calls made, messages left]
Follow-up recommendations if patient contacted: [specific instructions]
Risks of leaving without complete evaluation were [documented/not documented] with patient.

[Provider name, credentials]
[Date and time of documentation]

Common Pitfalls to Avoid

• Incomplete documentation: Failing to document the patient's clinical status at the time they were last seen 7
• Judgmental language: Using terms that imply blame or criticism of the patient's decision 1
• Missing follow-up plan: Not documenting attempts to contact the patient or recommendations for further care 2
• Failure to document time: Not recording when the patient was discovered to have left 5
• Lack of risk assessment: Not documenting potential concerns based on the initial evaluation 6

Thorough documentation of patients who leave before re-evaluation is essential for continuity of care and risk management. The medical record should clearly reflect the clinical situation, attempts to provide care, and follow-up recommendations to ensure patient safety despite the interrupted care episode.