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.