Providers
Not documented? Not done.

When you give a patient instructions, such as "follow up in 6 months for a blood pressure check" or "come back in 3 months for another blood test", you need to document that request in the patient's chart. (Documenting follow-up on a SuperBill or Encounter Form is not part of the medical record.) If you don't, you may be at risk.

Suggestion:
Have your office staff order you a stamp "FOLLOW UP ________." When your staff puts your patient in the exam room, they can stamp the medical record for that day's visit with the "Follow up" stamp. This will trigger you and other physicians to document to f/u instructions in the patient's medical record.