Outpatient Termination Letters

[Dr. Pookie]

New to outpatient private practice and looking to establish a protocol for handling ending the doctor-patient relationship in a way that mitigates risk appropriately. I know there are lots of scenarios that can lead to the end of a doctor-patient relationship (doctor terminates, pt. terminates, pt. lost to follow-up, pt. moves, etc.). In residency, the clinic I worked in always sent a termination letter (certified, first-class) regardless of the reason for termination. However, this seems tedious and unnecessary to me, especially if the patient initiates the end of the relationship (by all means, if I ended the relationship and had no intention of ever treating the patient again because of non-compliance, inappropriate behavior, etc., I'd send it certified).

I have a patient I've only seen for the intake appointment. For financial reasons (they didn't realize they had a huge deductible), they elected not to return for their first scheduled follow-up. They called to inform me of this. In addition to documenting that conversation in their chart before archiving it, do I really have to send a certified termination letter? No medications were prescribed on that first visit, but medical advice was given (ie. preliminary diagnosis, psychoeducation, etc.) I read that some people only send certified termination letters if the doctor initiated the termination. Would appreciate any insight/feedback. Thanks.

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[Crayola227]

You never "really have to" do any number of intelligent CYA things. Sending things certified mail isn't that hard or expensive. I would just emulate that like the prior clinic rather than save myself the work and risk whatever that clinic was avoiding with what they are doing.

 

[nexus73]

I would ask malpractice what they recommend. I worked in an hospital affiliated outpatient clinic with great support. So we could send a discharge (I prefer this to termination) letter to everyone, and it wasn’t a burden on me. It was very softly worded. Just served as official notice we would be available for emergencies for 30 days and after that they’d need to contact PCP or new psych provider, or ED/Crisis center. If you don’t have staff to do this it could be pretty annoying, and if malpractice says it’s not needed so be it. I think at least documenting you had a conversation to that effect would be pretty good.

 

[Bartelby]

If you use an EMR with messaging maybe send a termination letter? In the scenario you describe it probably is not necessary, but it at least makes it clear to the patient that the treatment relationship has ended (so for example they don't call you in crisis months later saying they did not know they couldn't).

 

[VA Hopeful Dr]

Check your state medical board website, they will have the bare minimum of what you need to include to avoid getting in trouble with them.

 

[Candidate2017]

It doesn't take much physical or mental energy to comply with state requirements. I have a handful of template discharge letters I reflexively pull off the shelf that cover any discharge situation. On the other hand, there are psychiatrists who stop answering calls or disconnect their office phone with nary a negative consequence.

I'm impressed your patient who met you once has the decency to call and let you know they can't return instead of no-showing (yes, the bar for human decency is low). A simple discharge letter that contains a line or two thanking them for their time and wishing them well goes a long way from a business/private practice standpoint. Thoughtful people remember thoughtful actions and generally surround themselves with thoughtful family/friends (referrals). And there's no reason to believe they won't return when their life situation, finances, job and insurance changes for the better.

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[Bartelby]

Seeing others' responses I did some googling. In California, for example, you do have to provide notice in writing of the last day you will provide care, other resources for care, and the process for obtaining their medical records (Terminating the Doctor-Patient Relationship / Patient Abandonment | Law Office of Nicole Irmer). So it sounds like looking up the rules for your specific board is important. A quick template could save you a lot of headaches later. I would double -check EMR v mailing as well, a patient portal message is written, secure, and might provide confirmation of receipt (while also being very easy to send).

 

[Bartelby]

Although even per that article if the patient consents to ending the treatment relationship then that is sufficient. I suppose the patient could claim that they never told you they wanted to end care, but that scenario seems pretty unlikely.

 

[MedMan80]

I hope people find this pdf usefull..

 

[hamstergang]

Although even per that article if the patient consents to ending the treatment relationship then that is sufficient. I suppose the patient could claim that they never told you they wanted to end care, but that scenario seems pretty unlikely.

If I trust the patient, then I just document that they wanted to end treatment with me and that's that.

If I don't quite trust the patient, then when they say they are ending treatment, I tell them I understand and will be sending them a letter about it to make it official. I don't want them to receive the letter as a surprise because that would feel like I'm saying, "No I'm the one breaking up with you."

 

[Sushirolls]

I lean heavily into my EMR and onboard all my patients electronically. This communication path is established. So I send an E message saying you got 30 days to schedule and keep your appointment or services close. Also attached to that E message is a scanned PDF of the same letter signed by me, which we put in the snail mail (not certified).

I keep a very tight list of knowing which patients are active, which are closed, and which are somewhat on their way out of being closed down.

 

[Jules A]

Unless I have significant concerns I just inform them I can prescribe 30 days and will be sending a DC letter. The letter via snail mail indicates it was nice getting to know them, outlines the conversation ie that they requested DC to pcp or whatever and includes a list of local clinics for med mgt and therapy. I put short free text note in chart. A psychiatrist I know does the same but always sends as certified letter.

 

[liquidshadow22]

I don't send letters by mail, only EMR.

I don't see this being an issue unless there is a reason to be concerned. Ie the patient was very high risk or there was some sort of dispute which could lead to board complaint.

Maybe it's cavalier but I don't have the staff to mail letters and I'm not wasting my time doing that

 

[Dr. Pookie]

Thanks for all the replies. I reached out to my malpractice and they basically divided it into physician-terminated and patient-terminated. For physician-terminated they recommended sending discharge letter via regular mail with delivery confirmation offering 30 days of meds/coverage, final discharge date, and community resources, process for records request, etc. They said, in their experience, people rarely sign for certified mail.

When patient-initiated discharge, they actually said I'm not required to provide notice, clinical coverage, or a termination letter, but that it would be prudent from a risk-management perspective. I feel like it would be the right thing to do regardless of who initiated the discharge, though.

In the end, I'll probably not bother with certified mail, but will send regular mail with return receipt in the case of a discharge initiated by me. For patient-initiated, I'll just send a portal message/email D/C letter. Both will get a blurb in the chart.

 

[allantois]

No one is as obsessed with this issue as we are in psych

 

[whopper]

Check your state medical board website, they will have the bare minimum of what you need to include to avoid getting in trouble with them.

Voila.

I used to live in Ohio and Ohio's laws had it covered on the exact way to do it. That was (at least last time I checked and this is by memory) sending the letter via certified mail, and a prescription 30 days of medication.

I currently am in Missouri. I've checked and found no guidelines.

Several textbooks recommend 3 referrals. I do that just in case.

I also will not give meds if I can cite a very defensible reason why. E.g. you were found abusing the prescribed medication and this is why I did not provide a month's prescription of this same medication.

If you do what the state laws recommend you're likely fine.

I've had two situations where the termination letter led to positive results. 1-patient was abusing Alprazolam and on Buprenorphine. 2-Patient wanted Clozapine but wasn't doing the labs. I terminated him. Months later his mother called and demanded I provide Clozapine despite that he was terminated and had no labs to provide. I refused even after telling her I was willing to keep an open mind and take him back if he did labs. He didn't. The idiot-mother complained to the state medical board. (I do not state idiot lightly. On several occasions the mother had behavioral disturbances in the waiting room and no not indicative of a frustrated and caring mother whose child had Schizophrenia but of a person wanting to cause trouble, being intentionally uncooperative, etc). The state medical board asked for a copy of the termination letter and once I presented it they said "case-closed. You had no doctor patient relationship."

Seriously, if you are going to terminate a patient they likely already are a major headache. They likely have personality factor that correlates with wanting revenge and messing up your life.