Did-not-keep-appointment doctor template

Did-not-keep-appointment (DNKA) Template

□ No Show □ Canceled ____________________

Initials

□ Rescheduled: ____________________ by _____________________

Date Initials

Per Dr. _____________________:

□ Reschedule

□ No need to reschedule

__________ __________

Initials Date

Patient Contacted:

□ By phone __________

□ By mail

_________ _________

Initials Date

Explanation: When patients fail to return to their physicians as advised, they may

contribute to their own injury. In litigation, some patients deny they were told to return.

Doctors should document in the patient’s chart the return date they suggested.

Appointment schedulers should document in the patient’s chart that patients missed,

canceled or rescheduled an appointment. This template can be made into a rubber

stamp for easy documentation of failed, canceled and rescheduled appointments.

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Did-not-keep-appointment doctor template
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