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Criterion 1.5.4 System for follow up of tests and results

The RACGP commissioned a legal opinion regarding a number of issues (including the issue of follow up) during the review of the Standards (2nd Ed). The legal opinion needs to be considered in relation to the original request for advice.

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

Explanation

This criterion focusses 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.

'Follow up' can have several meanings:

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

The GP's and practice's responsibilities reflect the recognition that the GP-patient 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 - nor 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 the review of the Standards for general practices (2nd Edition), members of the profession expressed concern about the way in which the RACGP would reflect the profession's standards in the area of follow up. Some of the profession felt the courts had inappropriately shifted patient responsibilities on to GPs. Others commented that the decisions of the courts were less important to them than the emotional consequences of missing clinically significant results. In response, the RACGP commissioned a legal opinion on the issue and considered that opinion and the views of the profession when preparing this edition of the Standards. The RACGP decided to provide lengthy detail in this explanation to assist in clarifying the issues for practices.

General practitioners are not legally responsible for everything that goes wrong, others (for example, the patient or a third party provider such as a pathology company) may be legally responsible instead of (or together with) the GP.

The practice needs a system aimed to ensure that:

• all received test results, and clinical correspondence (eg. reports from other health care providers or WorkCover letters) relating to a patient's clinical care are reviewed
• clinically significant tests and results are followed up.

The 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. 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 health care. 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).

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 also have responsibility in their own health care; 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 imagining 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.

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 upon - the records later. The standards for maintaining patient health records are covered in criteria 1.7.1, 1.7.2 and 1.7.3.

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 is unlikely to, or may not either 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 the 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 the rare case 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 inactions). This discussion between the GP and patient needs to be recorded comprehensively in the patient health record (criterion 1.2.2).

In a case where the 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. Review and action on results or reports 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.

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 involves devising, implementing and monitoring systems in the practice.

The RACGP recognises that information technology can be a useful tool in follow up, however the current clinical information systems have limitations and may not provide sufficient safeguards to be relied on in all cases. The RACGP has requested that the medical record software companies focus on the development of reliable systems for the follow up of tests and results as a high priority.

After hours care services 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.

Indicators

1. our patient health records contain evidence that pathology results, imaging reports, investigation reports and clinical correspondence received by our practice have been:
   • reviewed by a GP
   • initialled, and
   • where appropriate, acted upon in a timely manner (health records review).
2. our GP(s) and staff 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, and
   • incorporated into the patient health record (interview).
3. 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 (document review).
4. our GP(s) and staff can describe how patients are advised of the process for the follow up of results (interview).
5. our GP(s) and staff can describe the procedure for follow up and recall of patients with clinically significant tests and results (interview).
6. our practice has a system to recall patients with clinically significant tests and results (document review).
7. our practice has a written policy to follow up and recall patients with clinically significant tests and results (document review).

Publication Date: 18 July 2007
Authorised By: Standards