I try to review the chart at the preceding visit. As much as possible, for monitoring labs for the management of chronic medical problems, I try to order them in advance at the preceding visit to be drawn 1 week before the next follow up visit, and then I review them with the patient at that follow up visit, modify my therapy as indicated, and use the Updox portal to send a clinical summary to the patient immediately thereafter that automatically has the labs, but they have already heard the interventions if any from me at the visit. Even if the patient is reluctant to schedule a f/u for a chronic problem, I hand them the appropriate lab requisition at the end of every visit to get done 1w before the next visit they do decide to later schedule. The key for me is not to let patients leave without a thought out decision of when they need to come back so I can plan for that return visit. When patients at visits dedicated for f/u of chronic problems introduce new problems requiring different labs, I handle that separately just as if they made an unscheduled visit for a new problem as below.
For FFS patients coming in for new problems of which I know nothing in advance, I'll order the appropriate labs during the first visit and suggest a follow up visit at an appropriate interval to review the results.
I try not to have results coming in after a visit without a follow up visit to act upon them and generate the reimbursement for the time spent doing so.
For capitated patients I will sometimes alter this when it is clinically acceptable to do so, and generate appropriate monitoring lab requisitions with future dates instructing patients to call 1w thereafter for results. As about 80% of my lab results show stability not necessitating a change in therapy, when the results come in, I annotate a message to the effect "no new intervention required" and when the patient calls, my staff immediately gives the inquiring patient that message without a second call back. We let the patient know it is our expectation that they will call us for all lab results not preceding a scheduled appt - that way if they don't call, we don't worry about not informing them of normal results, and just chase the abnormals. I'll use this method as well for patients wanting to avoid a second copay where the patient and I were just seeking the reassurance of normal results ruling out a rarer cause of a more common self-limited problem, and for infrequently seen patients for routine physicals whose labs almost always return normal. When unexpected abnormal results return, my staff call the patients to schedule an appointment to address them.
We use the same approach for prescription refills. At every visit, the appropriate interval f/u is recommended, and all prescriptions needing refilling before that f/u visit are done before they leave. In this way, we try to minimize calls for refills to only those patients who elect not to make a recommended interval f/u appointment - and those patients are told they need to be seen. We also do not give out our fax number to any pharmacy or accept calls from pharmacies for refills - only from patients. 99% of our pharmacy calls are for expired prescription numbers that have already been renewed at a recent visit and are in the pharmacy's database, but the pharmacies uniformly don't bother to check. Most of the time the patient has already picked up that renewal and it is just an automated fax trolling for a refill not requested by the patient. I deny every NewCrop refill request with the response "have the patient call". I also try to synchronize all prescribing of medications for stable problems to once a year on the same date, and any later added medications are refilled just enough times to synchronize with that yearly refill date. Of course it doesn't work every time, but we have cut our phone calls and faxes by a lot. The challenge is to educate the patients to tell the pharmacy to check for the new renewal, not old prescription number.
