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Standards for health services in Australian prisons

Criterion 1.5.4 System for follow up of tests and results

Our health service has a system to review and follow up tests and results.


Indicators

A. Our patient health records contain evidence that pathology results, imaging reports, investigation reports and clinical correspondence received by our health service have been (health records review):

  • reviewed by a GP
  • initialled, and
  • where appropriate, acted upon in a timely manner.

B. Our staff can describe the system by which pathology results, imaging reports, investigation reports, and clinical correspondence received by our health service are (interview):

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

C. Our health service has a written policy describing the review and management of pathology results, imaging reports, investigation reports and clinical correspondence received by our service (document review).

D. Our staff can describe how patients are advised of the process for following up results (interview).

E. Our staff can describe the procedure for follow up and recall of patients with clinically significant tests and results (interview).

F. Our health service has a system to recall patients with clinically significant tests and results (document review).

G. Our health service has a written policy to follow up and recall patients with clinically significant tests and results (document review).


Explanation

This criterion focuses on the systems that health services need to use to follow up tests and results as part of their duty of care to patients.

The information gained from tests and results can have considerable impact on the choices patients and health professionals 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 health service
  • following up the patient – chasing or tracing the patient to discuss the report, test or results after they have been received by the health service and reviewed, or if the patient did not present for a test as expected.

The relationship between a health professional and a patient is characterised by trust and by the health professional having special knowledge and skills that the patient generally does not have. While health services 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 the review of the RACGP Standards for general practices (2nd edition), members of the general practice profession expressed concern about the way in which the RACGP would reflect the profession’s standards in the area of follow up. Some members of the profession felt the courts had inappropriately shifted patient responsibilities on to doctors. 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 which was taken into consideration along with the views of the profession when preparing the Standards. The RACGP decided to provide lengthy detail in this explanation to assist in clarifying these issues.

Medical and other clinical staff are not necessarily legally responsible for everything that goes wrong in a health service. Other people or entities (eg. a patient or a third party provider such as a pathology company) may be legally responsible for an adverse event instead of or together with a doctor or other health professional.

In some circumstances, people incarcerated in prisons will require the assistance of departmental staff to assist in the provision of their care (eg. arrange transport to attend offsite services). Health services in prisons will need to have a system in place to follow up such assistance, as it represents a link in the chain of care which may be broken and interrupt the continuity of care (eg. transport for an appointment may be overlooked if the prison management is busy or if resources required to facilitate the transfer of a patient are reallocated). Cooperation with the relevant government department may be particularly important in situations involving a clinically significant test result being received after a patient has been released from the prison.

The health service needs a system that is designed to ensure that:

  • all 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
  • individual cases receive appropriate 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 the circumstances. Overall, the following factors are important in determining whether something is clinically significant and therefore requires follow up:

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

The clinical significance of a test or result needs to be considered within the context of the patient’s history and presenting problems. Clinically significant results do not only arise from abnormal test 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. A result is deemed clinically significant when a GP or another member of the clinical team judges 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 further action may still be required.

The persistence with which a health service needs to facilitate further investigations will depend on the likelihood (as judged by a health professional) that the investigation, test or referral will be clinically significant and the degree of urgent action required.

The health service needs to have a working system for follow up – even if the system 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 a test or result, a reminder occurs. Medical and other clinical staff do not necessarily need to supervise the follow up system directly, but it needs to operate consistently and a GP or another member of the clinical team need to be responsible for identifying worrying cases.

The health service needs to be able to identify unexpected significant results when they occur, particularly if the significance of such results was not raised in the consultation. In these circumstances health services 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 a health professional and patient is a special one that is 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 be in a position to make good decisions. Decisions need to be based on information that doctors and other clinical staff have a duty to provide. Health staff need to convey such information to patients in a way that helps patients to understand it. A patient who makes a decision based on insufficient information is not making an informed decision. Once the patient is properly informed there can be legally effective informed consent, and there can also be legally effective informed refusal.

Patients too have responsibility for their own healthcare, including seeking their own results. It is important to have follow up systems in the health service that:

  • are meaningful for patients
  • create a shared understanding of what is going to happen
  • define who is responsible for follow up
  • encourage patients to discuss how they can help manage their own health.

These systems might include outlining the health service’s policy for follow up in the patient information sheet, and having GPs and other clinical staff routinely describe the health service’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 a patient’s care, the health service needs to reinforce the respective rights and responsibilities of patients and members of the health service team in following up tests and results. Developing this understanding with patients in a way that is easy for the patient to understand, reinforces to patients the need to think about the way in which they help to manage their own health. A brief and accurate note of these discussions is important to record in the patient’s file. In circumstances where the literacy of the patient is a problem, the health service would need to consider how to inform patients of their responsibility and follow up the results of recommended investigations.

Documentation of relevant clinical information is also required for health professionals who may require the records later. The standards for maintaining patient health records are covered in Criteria 1.7.1: Patient health records; 1.7.2: Health summaries and 1.7.3: Consultation notes.

Reliance on patient memory or motivation in place of an effective follow up system is not appropriate. Patients may not follow the recommendations provided by the health service because of their particular circumstances, fear, ignorance, personality, expectations, beliefs, cultural background or a range of other factors. Health services need to have systems that respond to situations where a particular patient is judged unlikely to go through with a test or follow up on the results.

In some instances, the results of investigations are sent to the health service rather than to the doctor who ordered the investigation. In such cases, the health service needs to have a follow up and recall system that identifies who in the service is responsible for the receipt, review and follow up of these results.

The location of the prison may also impact on the systems needed for follow up. For example, the proximity of consultant services to which patients can be referred may affect the way that investigations, tests and referrals are followed up in a system that is both appropriate and practicable.

Where a patient indicates they do no

Our health service has a system to review and follow up tests and results.

Indicators

A. Our patient health records contain evidence that pathology results, imaging reports, investigation reports and clinical correspondence received by our health service have been (health records review):

  • reviewed by a GP
  • initialled, and
  • where appropriate, acted upon in a timely manner.

B. Our staff can describe the system by which pathology results, imaging reports, investigation reports, and clinical correspondence received by our health service are (interview):

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

C. Our health service has a written policy describing the review and management of pathology results, imaging reports, investigation reports and clinical correspondence received by our service (document review).

D. Our staff can describe how patients are advised of the process for following up results (interview).

E. Our staff can describe the procedure for follow up and recall of patients with clinically significant tests and results (interview).

F. Our health service has a system to recall patients with clinically significant tests and results (document review).

G. Our health service has a written policy to follow up and recall patients with clinically significant tests and results (document review).

Explanation

This criterion focuses on the systems that health services need to use to follow up tests and results as part of their duty of care to patients.

The information gained from tests and results can have considerable impact on the choices patients and health professionals 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 health service
  • following up the patient – chasing or tracing the patient to discuss the report, test or results after they have been received by the health service and reviewed, or if the patient did not present for a test as expected.

The relationship between a health professional and a patient is characterised by trust and by the health professional having special knowledge and skills that the patient generally does not have. While health services 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 the review of the RACGP Standards for general practices (2nd edition), members of the general practice profession expressed concern about the way in which the RACGP would reflect the profession’s standards in the area of follow up. Some members of the profession felt the courts had inappropriately shifted patient responsibilities on to doctors. 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 which was taken into consideration along with the views of the profession when preparing the Standards. The RACGP decided to provide lengthy detail in this explanation to assist in clarifying these issues.

Medical and other clinical staff are not necessarily legally responsible for everything that goes wrong in a health service. Other people or entities (eg. a patient or a third party provider such as a pathology company) may be legally responsible for an adverse event instead of or together with a doctor or other health professional.

In some circumstances, people incarcerated in prisons will require the assistance of departmental staff to assist in the provision of their care (eg. arrange transport to attend offsite services). Health services in prisons will need to have a system in place to follow up such assistance, as it represents a link in the chain of care which may be broken and interrupt the continuity of care (eg. transport for an appointment may be overlooked if the prison management is busy or if resources required to facilitate the transfer of a patient are reallocated). Cooperation with the relevant government department may be particularly important in situations involving a clinically significant test result being received after a patient has been released from the prison.

The health service needs a system that is designed to ensure that:

  • all 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
  • individual cases receive appropriate 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 the circumstances. Overall, the following factors are important in determining whether something is clinically significant and therefore requires follow up:

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

The clinical significance of a test or result needs to be considered within the context of the patient’s history and presenting problems. Clinically significant results do not only arise from abnormal test 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. A result is deemed clinically significant when a GP or another member of the clinical team judges 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 further action may still be required.

The persistence with which a health service needs to facilitate further investigations will depend on the likelihood (as judged by a health professional) that the investigation, test or referral will be clinically significant and the degree of urgent action required.

The health service needs to have a working system for follow up – even if the system 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 a test or result, a reminder occurs. Medical and other clinical staff do not necessarily need to supervise the follow up system directly, but it needs to operate consistently and a GP or another member of the clinical team need to be responsible for identifying worrying cases.

The health service needs to be able to identify unexpected significant results when they occur, particularly if the significance of such results was not raised in the consultation. In these circumstances health services 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 a health professional and patient is a special one that is 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 be in a position to make good decisions. Decisions need to be based on information that doctors and other clinical staff have a duty to provide. Health staff need to convey such information to patients in a way that helps patients to understand it. A patient who makes a decision based on insufficient information is not making an informed decision. Once the patient is properly informed there can be legally effective informed consent, and there can also be legally effective informed refusal.

Patients too have responsibility for their own healthcare, including seeking their own results. It is important to have follow up systems in the health service that:

  • are meaningful for patients
  • create a shared understanding of what is going to happen
  • define who is responsible for follow up
  • encourage patients to discuss how they can help manage their own health.

These systems might include outlining the health service’s policy for follow up in the patient information sheet, and having GPs and other clinical staff routinely describe the health service’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 a patient’s care, the health service needs to reinforce the respective rights and responsibilities of patients and members of the health service team in following up tests and results. Developing this understanding with patients in a way that is easy for the patient to understand, reinforces to patients the need to think about the way in which they help to manage their own health. A brief and accurate note of these discussions is important to record in the patient’s file. In circumstances where the literacy of the patient is a problem, the health service would need to consider how to inform patients of their responsibility and follow up the results of recommended investigations.

Documentation of relevant clinical information is also required for health professionals who may require the records later. The standards for maintaining patient health records are covered in Criteria 1.7.1: Patient health records; 1.7.2: Health summaries and 1.7.3: Consultation notes.

Reliance on patient memory or motivation in place of an effective follow up system is not appropriate. Patients may not follow the recommendations provided by the health service because of their particular circumstances, fear, ignorance, personality, expectations, beliefs, cultural background or a range of other factors. Health services need to have systems that respond to situations where a particular patient is judged unlikely to go through with a test or follow up on the results.

In some instances, the results of investigations are sent to the health service rather than to the doctor who ordered the investigation. In such cases, the health service needs to have a follow up and recall system that identifies who in the service is responsible for the receipt, review and follow up of these results.

The location of the prison may also impact on the systems needed for follow up. For example, the proximity of consultant services to which patients can be referred may affect the way that investigations, tests and referrals are followed up in a system that is both appropriate and practicable.

Where a patient indicates they do not intend to take a recommended test, the health service needs to ensure the patient has received sufficient information to make an informed decision and to understand the consequences of their actions or inactions. This discussion needs to be recorded in the patient health record (see Criterion 1.2.2: Informed patient consent).

The review of 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 a patient to discuss the results, will depend on the health professional’s judgment of the clinical significance of the result/report, and the context, duration and longevity of the clinical relationship. If the health service needs to initiate follow up contact with a patient, it needs to do so in a reasonable manner. Attempts to contact a patient to follow up test results need to be documented in the patient’s health record.

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

  • the quality and content of discussions with the patient
  • the recording of those discussions
  • the recording of the clinical encounter
  • the person to whom the results are returned (eg. the health service versus the treating clinician).

It is useful for health services to understand that protecting patients and health professionals from errors involves a series of safeguards within a well designed system that is routinely adhered to.

The RACGP recognises that information technology can be a useful tool in follow up but cautions health services to be aware of the limitations of clinical information systems.

t intend to take a recommended test, the health service needs to ensure the patient has received sufficient information to make an informed decision and to understand the consequences of their actions or inactions. This discussion needs to be recorded in the patient health record (see Criterion 1.2.2: Informed patient consent).

The review of 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 a patient to discuss the results, will depend on the health professional’s judgment of the clinical significance of the result/report, and the context, duration and longevity of the clinical relationship. If the health service needs to initiate follow up contact with a patient, it needs to do so in a reasonable manner. Attempts to contact a patient to follow up test results need to be documented in the patient’s health record.

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

  • the quality and content of discussions with the patient
  • the recording of those discussions
  • the recording of the clinical encounter
  • the person to whom the results are returned (eg. the health service versus the treating clinician).

It is useful for health services to understand that protecting patients and health professionals from errors involves a series of safeguards within a well designed system that is routinely adhered to.

The RACGP recognises that information technology can be a useful tool in follow up but cautions health services to be aware of the limitations of clinical information systems.

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