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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.3

System for follow up of tests and results

Our practice has a system for the follow up and review of tests and results.

Indicators

► A. Our patient health records contain evidence that all pathology results, imaging reports, investigation reports and clinical correspondence received by or performed in our practice have been:

  • reviewed by a GP
  • signed or initialled or electronic equivalent
  • where appropriate, acted upon in a timely manner.

► B. Our practice team can describe the system by which pathology results, imaging reports, investigation reports and clinical correspondence received by our practice are:

  • reviewed
  • signed or initialled (or the electronic equivalent)
  • acted on in a timely manner
  • incorporated into the patient health record.

► C. Our practice has a written policy describing the review and management of pathology results, imaging reports, investigation reports and clinical correspondence received by our practice.

► D. Our practice team can describe how patients are advised of the process for the follow up of results.

► E. Our practice team can describe how we follow up and recall patients with clinically significant tests and results.

► F. Our practice has a documented system to identify, follow up and recall patients with clinically significant results.

Explanation

Key points

  • The practice needs a documented system for the follow up of tests and results, with a strong focus on risk management
  • The practice system should delineate mechanisms for dealing with normal results, abnormal results (urgent and non urgent) and important tests/referrals
  • The practice system should delineate mechanisms for the follow up of results and the follow up of clinically significant tests
  • The practice system should cover how tests and results are communicated to patients.

Definitions

‘Follow up’ can mean:

  • following up the information – following up on tests and results that are expected but have not yet been received by the practice
  • following up the patient – tracing the patient to discuss the report, test or results after they have been received by the practice and reviewed, or tracing the patient if the patient did not take a test as expected.

‘Recall’ means:

  • a system to make sure patients receive further medical advice on matters of clinical significance. 

‘Clinical significance’ is determined by:

  • the probability that the patient will be harmed if further medical advice is not obtained
  • the likely seriousness of the harm. 

‘Follow up system’ is required by the practice to ensure that:

  • all received test results and clinical correspondence (eg. reports from other healthcare providers) relating to a patient’s clinical care are reviewed
  • clinically significant tests and results are followed up
  • patients are made aware of the seriousness of not attending for follow up
  • patients are made aware of who is responsible for communicating with whom about results and when this is to occur.

A rigorous follow up system is essential

This criterion focuses on the systems that general practices need to use to follow up tests and results. The information gained from tests and results can have considerable impact on the choices patients and GPs make in patient care.

The GPs’ and practice’s responsibilities reflect the recognition that the patientdoctor relationship is a special one based on trust. It is also characterised by the GP having special knowledge and skills that the patient generally does not have. While practices are not expected to follow up every test ordered, or to contact patients with the results of every test or investigation undertaken, there may be considerable risk in not following up clinically significant tests and results.

During previous reviews of the RACGP Standards for general practices, members of the profession expressed concern about the way in which the College would reflect the profession’s standards in the area of follow up. Some felt the courts had inappropriately shifted patient responsibilities to GPs. Others commented that decisions of the courts were less important than the emotional consequences of missing clinically significant results. In response, the RACGP commissioned a legal opinion on the matter from Milstein and Associates and that advice has been incorporated in the Standards.

The follow up system needs to be designed in a way that anticipates that individual cases will require different levels of follow up depending on the clinical significance of the case.

Reliance on patient memory or motivation alone does not reduce the need for an effective follow up system in the practice. Patients may not follow the recommendations for tests provided by the practice because of their particular circumstances, fear, ignorance, personality, expectations, beliefs, cultural background or a range of other factors. The practice needs to have systems to identify and respond to situations where a particular patient may not understand or comply with their responsibilities to go through with a test or to follow up the results with the practice. General practitioners in the practice need to reflect on which patients, tests and results justify a suspicion or concern. The practice needs to have a system that will allow GPs to take action to address their concerns. These concerns could be based on suspicion that the information from a test is likely to be clinically significant, or that the patient might not have the test performed.

In cases where a GP suspects that the results will be clinically significant, the practice needs to create additional safeguards to ensure that potentially clinically significant information does not get ‘lost in the system’. One approach is by obtaining a clearly expressed agreement from the patient (which is documented by the GP) that the patient is responsible for having the recommended tests performed and/or getting the results. However, this alone might not be sufficient for follow up in all circumstances. The practice needs to have a system that protects against the failure of both the GP and the patient remembering to follow up on tests or results. These systems need to allow for more intensive follow up action if required by the circumstances.

Follow up systems in a group practice

In a group practice, it is ideal for all GPs to have the same system for the follow up of tests and results. This consistency will ensure that all members of the practice team are fully aware of the practice system. If there are different follow up systems in place for different doctors in the practice, this needs to be very carefully documented to ensure the follow up of tests and results is managed effectively across the whole practice.

Clinical significance

The nature and extent of responsibility for following up tests and results will depend on what is reasonable in all of the circumstances. Overall, the following factors are important in determining if something is clinically significant and therefore requires follow up:

  • the probability that the patient will be harmed if adequate follow up does not occur
  • the likely seriousness of the harm
  • the burden of taking steps to avoid the risk of harm.

The clinical significance of a test or result needs to be considered in the overall context of the patient’s history and presenting problems. Clinically significant results do not necessarily only mean ‘abnormal’ results. For example, a normal mammogram in a woman with a breast lump, or a normal electrocardiogram in a patient with chest pain, does not preclude the need for further consultation, investigation and management. ‘Clinically significant’ is a judgment made by the GP that something is clinically important for that particular patient in the context of that patient’s healthcare. The judgment may be that an abnormal result is clinically important and requires further action. On the other hand, the result may be normal, but may still require further action.

The practice needs to have in place some process or system for following up – even if it is as basic as a simple diary entry or logbook containing ‘worrying’ or ‘high risk’ cases – so that where there is a concern about the significance of the test or result a reminder occurs. General practitioners do not necessarily need to supervise such a system directly, but it needs to operate consistently where it is needed (although the GPs will be the ones who identify the ‘worrying’ cases).

Communicating tests and results to patients

The practice needs to be able to identify unexpected significant results when they are received, particularly if the significance of such results was not raised in the consultation. In these circumstances practices need to alert the patient, who may not anticipate or understand the significance of the result.

Problems in follow up can be avoided or minimised through interventions at earlier points in patient care. The relationship between doctor and patient is a special one, based on trust and communication. While the patient is the ultimate decision maker, it is important for the patient to be well informed in order to make such decisions. Decisions need to be based on information that the GP has a duty to provide. The GP needs to convey the information to the patient in a way that helps the patient to understand it. A patient who makes a decision based on insufficient information is not making an informed decision. Once properly informed, however, there can be legally effective informed consent, and there can also be legally effective informed refusal.

Patients’ obligations

Patients also have responsibility for their own healthcare; this includes the seeking of results. It is important to have follow up systems in the practice that are meaningful for patients; that create a shared understanding of what is going to happen; that define who is responsible for follow up and that encourage patients to discuss how they can help manage their own health. These systems might include outlining the practice’s policy for follow up in the patient information sheet, placing a notice in the waiting area, and having the GPs and clinical staff routinely describe the practice’s system for follow up to patients when requests for pathology or imaging tests are made. The standards for ensuring that patients have the information they need to make informed decisions are covered in Criterion 1.2.2 Informed patient decisions.

At an early stage in the patient’s care, the practice needs to focus on the reinforcement of the respective rights and responsibilities of the patient and members of the general practice team in following up tests and results. Developing this understanding with patients reinforces for patients that they should actively engage with the GP and that part of this requires them to think about the way they help manage their own health. Brief but accurate documentation of the discussion and outcome of such discussions is important. Documentation of relevant clinical information is also required so that the information provides a trigger to the GP or to others who may view, and rely on, the records later. The standards for maintaining patient health records are covered in Criterion 1.7.1 Patient health records, Criterion 1.7.2 Health summaries and Criterion 1.7.3 Consultation notes.

Where a recommended test is refused

In rare cases where a patient indicates they do not intend to comply with the recommendation for a test, the practice needs to ensure that the patient has received sufficient information with which to make an informed decision and to understand the consequences of their actions (or inaction). This discussion between the GP and patient needs to be recorded comprehensively in the patient health record (see Criterion 1.2.2 Informed patient decisions).

Timely review and action on tests and results

The review of results or reports and related action needs to be completed in a timely manner. The speed with which results/reports are acted on and the degree of effort taken to contact the patient to discuss the results will depend on the GP’s judgment of the clinical significance of the result/report and the context, duration and longevity of the clinical relationship. If the practice needs to initiate follow up contact with a patient, it needs to do so in a reasonable manner. The number and types of attempts will take into account all of the circumstances. Depending on the likely harm to the patient, three telephone calls at different times of the day and follow up by mail to the address in the patient’s health record may be needed. These attempts at follow up need to be documented in the patient’s health record.

What most commonly goes wrong

A close analysis of how and when things go wrong in the follow up of patients with clinically significant tests or results often shows that it is a problem, or several problems, with the practice system including:

  • the quality and content of discussions with the patient
  • the recording of those discussions
  • the recording of the clinical encounter.

It is therefore useful for practices to understand that protecting patients and GPs from errors involves a series of safeguards and devising, implementing and monitoring systems in the practice.

Practice software

The RACGP recognises that information technology can be a useful tool in the follow up of tests and results. The RACGP supports the development of reliable systems for the follow up of tests and results by the medical software industry as a high priority.

Services providing care outside normal opening hours

Services that provide care outside normal opening hours need to have a system to ensure that all received results and clinical correspondence relating to a patient’s clinical care are reviewed and that clinically significant tests and results are followed up by the medical practitioner who ordered the test, with copies forwarded to the patient’s regular GP.

Standard 1.5 Continuity of care

Our practice provides continuity of care for its patients.

Criterion 1.5.3

System for follow-up of tests and results

Our practice has a system for the follow up and review of tests and results.

In a nutshell

A rigorous follow-up system for tests and results is essential to minimise potential harm to patients and ensure your health service meets its clinical and legal obligations to patients. Documenting your follow-up system is the key to maintaining consistency and minimising potential risks from failure to adequately follow up tests and results. It is recommended your health service’s follow-up system clearly defines areas of risk and develops mechanisms for dealing with them. An effective follow-up system clearly sets out:

  • 
different mechanisms for dealing with normal results, abnormal results (urgent and non-urgent) and important tests or referrals
  • 
different mechanisms for the follow-up of clinically significant results and of clinically significant tests
  • 
how tests and results are communicated to patients to ensure they have sufficient information to make informed decisions.

Key team members

  • Health service manager
  • Clinical staff
  • Reception staff

Key organisational functions

  • Recall system and processes
  • Follow-up system and processes
  • Pathology review and management policy
  • Patient communication policy and processes
  • Patient informed consent
  • Patient health record
  • Patient records management system

Indicators and what they mean

Table 1.11 explains each of the indicators for this criterion. Refer to Criterion 1.5.3 System for follow up of tests and results of the Standards for general practices for explanations of some of the concepts referred to in this criterion.

Table 1.11 Criterion 1.5.3 System for follow-up of tests and results
IndicatorWhat this means and handy hints
▶ A. Our patient health records contain evidence that all pathology results, imaging reports, investigation reports and clinical correspondence received by or performed in our practice have been:
  • reviewed by a GP
  • signed or initialled (or the electronic equivalent)
  • where appropriate, acted upon in a timely manner.
Part of your health service’s follow-up system provides that patient health records contain all relevant information about pathology tests and results, their review by a GP and the discussions the GP has with patients about their results. This requires that the following are recorded in your patient health records:
  • all pathology results, imaging reports, investigation reports and clinical correspondence received by your health service
  • a GP’s review of pathology results and reports, and notes on the follow-up instructions required
  • a GP’s signature or initial for each review
  • a record of when and what action was taken, if follow-up has occurred. This needs to be done in a timely manner, and to refer to the mechanisms in place to deal with different types of results (normal, abnormal, clinically significant)
  • discussions with patients, including a brief but accurate record of patient discussions and outcomes when communicating clinically significant results and tests.
▶ B. Our practice team can describe the system by which pathology results, imaging reports, investigation reports and clinical correspondence received by our practice are:
  • reviewed
  • signed or initialled (or the electronic equivalent)
  • acted on in a timely manner
  • incorporated into the patient health record.
It is important that your health service’s follow-up system provides clear guidelines about how results and tests are processed, and includes:
  • a description of who has responsibility for reviewing test results, and how they document that review process
  • details of who can sign or initial the test results, and how they document that process
  • details of who determines the next course of action, including the type of action required (follow-up on information; follow-up with patient; recall the patient) and the level of urgency attached to the action, as well as how they document that process
  • a description of the processes and circumstances where investigation results are incorporated into the health record (by the GP once it has been reviewed, or by another clinical staff member upon consultation with the GP).
▶ C. Our practice has a written policy describing the review and management of pathology results, imaging reports, investigation reports and clinical correspondence received by our practice. Your health service has a written policy that sets out a process for review and management of results. This policy clearly states:
  • the people with responsibility for reviewing results
  • the processes to deal with:
    • normal results
    • abnormal results
    • urgent results
    • non-urgent results
    • follow-up of tests
    • follow-up of clinically significant results
  • who has responsibility for contacting patients for follow-up and recall
  • a definition of timeliness, with a process to deal with situations where both patient and GP may forget to follow up results and tests
  • how follow-up information can be communicated with patients, and the circumstances in which different kinds of communication are appropriate (phone, email, by mail, face-to-face)
  • the processes and circumstances for incorporating the results into the health record (always by the GP once it has been reviewed, or by another clinical staff member upon consultation with the GP)
  • the kind of information required to be recorded in patient records with regards to review and management of results (such as when patients are contacted, how often they were contacted, and a record of clinical conversations with patients)
  • the provisions for timely review and action on results.
▶ D. Our practice team can describe how patients are advised of the process for the follow-up of results. Your health service has a written policy about communicating pathology results, and the process for follow-up of results, to patients. The earlier this is done in the doctor–patient relationship, the better.

This process should be reinforced by other clinical staff members and reception staff when the opportunity arises. This could be done by adopting different strategies for different members of the team:
  • the clinical team could provide information about the process during the first clinical consultation, prior to tests being ordered, and when results are communicated to patients
  • the reception team could provide information via phone, at reception, by handing out patient information brochures or by prominently displaying information about the process in the reception area.
Where appropriate, your service should endeavour to provide patients with the information in their community language, or through the use of interpreters or visual representation. You should also consider culturally safe clinical practice in the delivery of test result information to patients of Aboriginal and Torres Strait Islander descent.
▶ E. Our practice team can describe how we follow up and recall patients with clinically significant tests and results. Members of your clinical and reception staff clearly understand the difference between clinically significant tests and clinically significant results, and the health service’s follow-up and recall process for both. Staff can demonstrate that they have an understanding of patient confidentiality and privacy when actioning follow-up and recall procedures. They are also aware of where to find the written policy and processes when required.
▶ F. Our practice has a documented system to identify, follow up and recall patients with clinically significant results. Your health service has a written policy that sets out a process for follow-up and recall of patients with clinically significant results. The policy includes:
  • a definition of clinically significant results
  • a statement that responsibility for reviewing and identifying clinically significant results rests with the GP
  • details about the follow-up process, clearly outlining the roles and responsibilities of different staff members
  • an outline of the kind of information different staff members can convey, and how they can convey it. If, for example, reception staff are identified as having responsibility for contacting patients with significant results to make an appointment, the outline indicates how they could do so (for example, ‘Your doctor wants you to make an appointment [indicate when] to discuss the results of your recent tests’)
  • guidelines about the kind of information that needs to  be recorded (contact details, clinical discussions and outcomes) in patient health records
  • where appropriate, provision of standardised forms and letters for follow-up and recall of patients
  • provision for timely review and action on tests and results.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure appropriate follow-up of tests and results for its patients. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The health service policy and procedure manual clearly sets out the process and documentation required for the follow-up and review of tests and results, including clinically significant tests and results. It also identifies who is responsible for managing the process. The policy and procedure manual incorporates a flow chart clearly showing the review and recall process and this flow chart is displayed in consulting rooms and at reception.

The staff induction process includes the system of following up tests and results, including clinically significant tests and results. The service’s staff members’ understanding of the system for following up clinically significant tests and results is consistent with the organisation’s documented policy and process.

The documents that reception staff scan into patient health records relating to tests, results or specialists’ appointments have been reviewed, dated, initialled and actioned as required.

The service uses a clinical software program to manage recalls. The appointment book has urgent appointments available for those patients who need to be recalled, either on the day or the day after. Reception staff flag patients in the appointment book who have appointments for a recall and these patients are not removed from the recall list until they have attended their appointment. When an appointment is made for a patient for recall, the appointment date and time is documented in the patient’s health record.

It is clearly explained to patients why it is important that they have the tests ordered by the GP.

Patient health records show evidence of results being reviewed, actioned and patients being recalled for further care. Staff members document in patient health records attempts made to contact patients for recall – for example, date, time, method (phone, letter, physical visit) and if an attempt was successful or not.

Transport drivers often hand-deliver letters or messages to patients, letting them know that staff members at the service are trying to contact them. The transport driver will also phone the service to make appointments for patients and book transport at the same time, if required.

Showing how you meet Criterion 1.5.3

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Ensure that pathology results in patient health files show evidence of review by GPs as required.
  • Ensure patient health files show a record of attempts to contact and recall patients in relation to clinically significant tests and results.
  • Ensure patient health files show when follow-up has occurred, and treatment if any required.
  • Document the review and recall system, including who is responsible for monitoring and follow-up of recalls.
  • Ensure and show that staff induction includes the review and recall system.
  • Show that you cover follow-up in staff interviews.
  • Audit health records.
  • Maintain in-service training records.
  • Maintain flow charts of processes.
  • Include follow-up in job descriptions.
  • Maintain templates within a clinical software program.
  • Maintain a policy and procedure manual.
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