The Doctor’s Advocate | First Quarter 2024

Proactively Manage Patient Expectations With a Conditions of Treatment Agreement

Debra Kane Hill, MBA, RN, Senior Patient Safety Risk Manager, and Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company

A review of The Doctors Company call data shows that patient relationship issues are the top reason that members request assistance. Our patient safety risk managers often assist with issues involving new patients whose behaviors raise red flags during their very first encounter with the practice.

Unfortunately, difficult patient interactions have become more common—with both established and new patients. Frequent issues reported include rudeness, entitled attitudes, abusive language, drug-seeking behaviors, unrealistic expectations, threats to staff, and intimidating language about pursuing legal action if expected needs are not met. These challenging interactions are time consuming and drain staff resources, contribute to practitioner and staff burnout, and can lead to licensing board complaints and claims. To mitigate adverse consequences and protect your practice, consider developing a plan to preemptively manage challenging behaviors when they are first identified.

Consider the following examples: During a plastic surgery patient’s first encounter, the patient tells the checkout receptionist, “I will sue if I don’t have good results.” The practitioner must be made aware of this type of statement in order to address patient expectations and determine if an ongoing relationship is appropriate. Another example is a new patient who requests controlled substances, then intimidates the practitioner if the demands are not met. In this situation—particularly if the behavior is threatening—it may be wise to deny the individual acceptance into the practice from the start.

Once the practitioner-patient relationship is established (which typically occurs with the first encounter), the practice assumes care for the patient until steps are taken to dismiss the patient from the practice if it becomes necessary.

Not everyone who seeks care is a good match for a practice. Assessing potential patients before accepting them into the practice is an important risk mitigation strategy. While it may be unrealistic to evaluate every potential patient who presents to a busy family medicine or pediatric practice, it is prudent to do so in some specialties, such as plastic surgery, pain management, and psychiatry.

Create a Conditions of Treatment Agreement

Developing a “Conditions of Treatment” (also called a “Terms of Service”) agreement for prospective patients can help practices determine whether an individual is a good fit for the practice. For transparency, notify individuals at the outset about the practice’s expectations for established patients.

Use a clearly written Conditions of Treatment agreement that outlines the practice’s office policies. It can include rules for payment, appointment scheduling and cancellation, no-show fees, decorum toward staff and visitors, weapons, personal hygiene, service animals, audio or video recording, and personal electronic devices (including smartphones).

The agreement can also specify expectations for the patient’s adherence with recommended treatment plans, specialty referrals, therapies, and medication regimes. Without the patient’s agreement, optimum clinical outcomes may be compromised and the trust necessary to support the practitioner-patient alliance may be eroded.

Clearly indicate in the Conditions of Treatment agreement that failure to follow the practice’s policies may result in dismissal from the practice.

Evaluate Prospective Patients and Manage Established Patients

Consider these steps to help you evaluate potential patients and define expectations:

  • Post a statement, such as the following, on your practice website, in your waiting room, and on new encounter office forms: “We evaluate potential patients to determine if they are a good match with our practice and the services we offer. Completing office forms, providing patient records, or attending an appointment for an initial evaluation does not establish a practitioner-patient relationship. After the initial evaluation, individuals will be notified if they are accepted into the practice as a patient.”
  • Provide the Conditions of Treatment agreement for review at the first office encounter.
  • Conduct an initial evaluation of the individual at the first encounter to assess clinical needs and expectations and determine any behavioral challenges. Document these findings in your records. Notify the individual at the end of the visit about acceptance into the practice.
  • Document your acceptance of an individual into the practice in the new patient’s record. You may bill those who are accepted as patients.
  • Have accepted new patients sign the Conditions of Treatment agreement that outlines expected behavior, office operations, and potential consequences if the patient violates office policies.
  • Always send a letter (by first-class mail and certified mail, return receipt requested) to individuals who are denied acceptance into the practice, and place a copy in administrative files. Include wording that “a practitioner-patient relationship was not established” and the individual will not be charged for the encounter. Never prescribe medications or treatments for those who are denied acceptance into the practice, and do not bill for the evaluation. These actions suggest that a practitioner-patient relationship was established.
  • Do not refer to those individuals not accepted as “patients.”
  • Ensure that individuals are not denied based on Equal Employment Opportunity Commission or Americans with Disabilities Act protected status. For example, denying individuals acceptance to your practice because they require an interpreter is illegal.
  • Post your office policy requirements on the practice’s website. For established patients who violate office policies, it may be helpful to sit down with the patient to go over the Conditions of Treatment and address specific issues.
  • For repeat violations of office policies, send the patient a letter that identifies the problem, reminds the individual about the signed agreement to obey office rules and policies, and states that continued inappropriate behavior may result in discharge from the practice. Place a copy of the letter in the patient’s record.
  • Display signage near the reception window regarding deductible payments, assessed charges for missed appointments, possession of weapons, and other simple reminders to facilitate interactions with office staff and help expedite routine patient processing.
  • Provide concise, accurate, and complete documentation of patient interactions conducted onsite in the office, through remote telehealth encounters, or via the patient portal. To promote continuity of care, document conversations among the treatment team in the progress notes.
  • Caution anyone entering the practice that there is a zero-tolerance policy for violence, brandishing weapons, and any form of sexual harassment. Employees of a healthcare practice are legally entitled to protection against unsafe working conditions, violence, and confrontational behavior. The practice is responsible for proactively helping to ensure compliance.
  • Create internal policies and procedures that define the new patient acceptance or denial process. Educate staff on applying these steps.

Practitioners and staff who anticipate, plan for, and appropriately respond to challenging behaviors with the assistance of a Conditions of Treatment agreement can protect the practice from risk.

Find additional resources or contact your patient safety risk manager at (800) 421-2368 or

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.