When the relationship between a physician and patient is terminated, the exact circumstances of the termination must be documented. The patient’s condition should be summarized in the same manner as a discharge note in a hospital record. For each ongoing medical problem that is identified, there should be evidence that the patient was notified of the problem and the need for further care. If the physician knows who the patient is transferring to, this should be recorded in the termination note.

A physician who terminates the physician–patient relationship must document that the patient was properly notified. The physician should write a termination note in the patient’s chart documenting that the patient was contacted and told of the physician’s decision, its medical implications, and where to obtain further care, if needed. This information should also be put in a letter to the patient. If possible, the patient should sign a copy of this letter during a visit with the physician. The physician should give the patient the original letter, keeping the signed copy for the files. If this is not possible, the letter should be sent by certified mail, with a return receipt requested. The certified mail number should be noted in the letter, and a copy of the letter and the return receipt should be put in the patient’s medical record. If the letter is returned and efforts to find a correct address fail, the unopened letter in the patient’s record will document that a diligent effort was made to contact the patient.

Patient-initiated terminations must be carefully documented. Although the patient always has the right to terminate the physician–patient relationship, this is usually done not by confronting the physician but passively by not returning for care. It is the physician’s responsibility to follow up on patients who disappear if they have conditions that require continuing medical care. (It is also good business to keep track of patients and their reasons for seeking care elsewhere.) These conditions may be acute, such as an orthopaedic patient who does not return to have a cast removed, or chronic, such as a diabetic.

Following up on missing patients requires that medical records be kept in such a manner that the physician is aware that a patient has been lost to follow-up. Tickler files serve as reminders that a patient is due to return for care. These may be computerized, or kept in a manual tickler file. When a patient misses an appointment, the physician should call to find out what has happened to the patient. If the patient cannot be located, refuses to come back, or has found care elsewhere, the physician should document this information in the chart. The physician should send the patient a certified letter explaining why the patient should return or find alternate care.