Domain 5 Organisational and legal dimensions

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

General practitioners (GPs) see patients from all walks of life, with a broad spectrum of presentations. The scope of general practice that each individual doctor practises within also varies significantly. GPs are well trained in being able to manage a range of individual patient needs; however, the quality of care provided depends on the organisation of care. GPs work in a complex system of regulatory bodies and organisations, and therefore need to understand the key principles of the practice environment and its processes, management and accreditation to ensure quality care. This includes at the practice, local, state and federal levels.

A core responsibility of GPs is to prescribe within the Pharmaceutical Benefits Scheme (PBS) rules and bill Medicare appropriately. In addition to prescribing within the scope of evidence-based medicine, a GP needs to adhere to the PBS regulations and Department of Veterans’ Affairs (DVA) regulations, and prescribe scheduled medicines, including S8 and S4 drugs safely, appropriately and in accordance with their jurisdiction’s regulations.1,2 In terms of using Medicare for their services, from consultations for medical issues to care plans and various procedures, a GP needs to ensure that their record keeping and the service provided within the consultation adhere to the descriptors of the item under the Medicare Benefits Schedule.3 There are also rules for private billing; for example, around workers’ compensation consultations and wound management, that a GP needs to be aware of and compliant with.

Another important aspect of practising as a GP is being aware of medico-legal responsibilities and avenues for support. Medical indemnity is an essential component of being a registered medical practitioner in Australia; however, it is also an important resource for advice and personal protection.4 GPs also need to understand their regulatory responsibilities regarding providing certificates, including for Centrelink, workers’ compensation and sickness, as well as the requirements for mandatory reporting, such as in cases of suspected child abuse.5

There are many resources and supports available for vulnerable groups, including for Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse groups, and refugees. GPs and practice staff need to understand the best methods for identifying these patients in a culturally safe manner.6 GPs also need to be aware of, and advocate for, programs such as the Closing the Gap initiative,7 and other resources and programs that could be beneficial to patient cohorts. GPs in rural and remote areas need to understand how to manage their time and priorities in their communities, as populations in these areas experiences significant disparities in terms of health access and promotion.

All patients have the right to confidentiality and informed consent. This is particularly important for vulnerable populations. GPs are required to understand these issues and act within legal and ethical boundaries.8 Appropriate record keeping and an effective recall system are essential tools in a practice’s framework that can help protect the rights and safety of both the patient and practitioner.9 Awareness and understanding of how to navigate the differences in state and federal laws for issues, such as voluntary assisted dying, regulations for telehealth and mandatory reporting responsibilities, are also essential. GPs also need to develop a good working relationship with their colleagues who can often offer guidance through their own lived experience as a practitioner navigating these complex organisational and legal dimensions.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Organisational and legal dimensions  
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs use effective practice management processes and systems to continually improve quality and safety
  1. maintain and improve quality in clinical practice standards and infection control
  2. demonstrate effective leadership 
  3. manage time and priorities efficiently  

Aboriginal and Torres Strait Islander health
  1. identify and implement effective models of primary healthcare delivery which meets the needs of Aboriginal and Torres Strait Islander peoples
  2. implement systems to support identification of Aboriginal and Torres Strait Islander patients
  3. facilitate timely and appropriate use of relevant Indigenous-specific health measures and MBS/PBS items
Rural health
  1. manage time and priorities efficiently when undertaking on-call roles 
  1. GPs work within statutory and regulatory requirements and guidelines
  1. manage patient privacy and confidentiality appropriately according to the relevant jurisdiction(s) 
  2. explain and obtain informed consent in a manner of shared decision-making
  3. describe and integrate medico-legal requirements, including record keeping 
  4. conduct business ethically and legally
  5. provide a practice environment that is culturally safe for themselves, their staff, patients and their families  
  6. ensure a work environment that is safe and supported and free of bullying, harassment and discrimination

Aboriginal and Torres Strait Islander health
  1. identify and implement appropriate policies and initiatives regarding Aboriginal and Torres Strait Islander health to optimise outcomes

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. It can be daunting figuring out how to navigate legal and organisational issues in general practice, as they aren't easily learnt from textbooks or journal articles. However, your colleagues are a great source of wisdom. Ask for advice from staff at your practice or your fellow trainees, or even informally through social media groups. It is important that you understand the limitations of informal advice, but these can be great resources for debriefing and support.
  2. You don’t have to completely solve every issue in a consultation. Uncertainty about regulations is common. It is important to recognise when there are uncertainties; communicate these to the patient, as they often understand the need for another consultation, and then spend time finding advice and resources on the issue. It is important to manage uncertainty about medico-legal issues early, rather than having to correct earlier inaccurate advice or actions.
  3. Early in your term, ask your supervisor and/or practice manager about specific vulnerable population groups that the practice might be seeing, such as refugee patients, Aboriginal or Torres Strait Islander patients, or lower-income groups. Identify local resources that you might use in these contexts.
  4. In the case of a complaint from a patient or concerns about missed results, etc, it is essential you seek advice from your medical defence organisation (MDO) early. They can provide comprehensive advice and support.
  5. Understand a practice’s processes for recalls, results, clinical documentation and risk mitigation early on when starting at a new practice. This is important while training and when you become an independent practitioner. Making sure these organisational processes are in place wherever you practice is important for patient safety.
  6. There might be new legislation about important clinical issues and MBS item numbers that you might miss as an independent practitioner. Make sure you have resources from the RACGP or MBS Online that you can check regularly to find important changes regarding these issues.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Domain 5 Organisational and legal dimensions

Steve is a 65-year-old man whose regular GP has recently retired. He has had an ongoing workers’ compensation claim for a lower back injury, for which he uses opioid medications. He would like you to take over his care and provide him with his scripts.

Questions for you to consider Clinical exam assessment area Domains

What strategies could you use to find out and address Steve's expectations? What if Steve was from a different culture or language group to you?

You decide you want to discuss Steve’s situation with a case worker. What would you say to Steve about the confidentiality of his medical information?

  1. Communication and consultation skills
1,2,5
 

What details of Steve’s history would need to be recorded in the notes?

How would you gather information about his opioid use?

How would you gather information about the ongoing claim and his past medical history?

How would you ensure Steve isn’t getting multiple scripts for opioids?

  1. Clinical information gathering and interpretation
2   

How would you assess the appropriateness of the ongoing workers’ compensation claim and limitations?

How would you assess the appropriateness of opioids for Steve’s condition? What if the time frame of his symptoms was months? What if it was years?

  1. Making a diagnosis, decision making and reasoning
2   

When would you refer to a non-GP specialist?

Who would potentially form part of the care team and how would you coordinate care?

If you were practising in a rural location, how would you manage the limitations around resources and allied health?

  1. Clinical management and therapeutic reasoning
2   

What supports are available to the patient and practitioner regarding opioid de-prescribing?

What other aspects of Steve’s healthcare should be addressed?

How will you engage Steve to address non-pharmacological management of his condition?

  1. Preventive and population health
1,2,3      
 

Where would you find information and/or education about workers’ compensation claims?

How do you ensure your notes are an accurate reflection of the consultation?

Do you have any personal biases towards chronic pain management that might impact this consultation or your record keeping? Would you feel differently if Steve was not on opioids?

If Steve gets upset because you cannot prescribe opioids today, how would you manage or de-escalate the situation?

  1. Professionalism
4   

How would you make sure an appropriate plan is in place and being adhered to?

What are the regulations around opioid prescribing in general practice?

You receive a request for a written report from the workers’ compensation body. What are the key considerations in completing the report?

If you think Steve is addicted to opiates, how does this change your legal responsibilities in your state or territory regarding prescribing for Steve?

  1. General practice systems and regulatory requirement
5   

How would you fill out a workers’ compensation certificate?

  1. Procedural skills
2   

Are there colleagues or senior doctors you could approach for advice regarding workers’ compensation claims or opioid prescribing? How would you go about this?

If it is unclear what is causing Steve’s pain, how would you approach his management?

  1. Managing uncertainty
2   

What would you do if Steve ended up with cauda equina syndrome? How would you manage this from a legal point of view?

How would you manage Steve’s condition in a rural area? What are some of the difficulties in terms of access and referral that you might encounter? How would you manage these?

When would you consider urgent imaging?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Find the workers’ compensation template specific to your state or territory and practise filling it in for a test/trial patient. Alternatively, do this for Centrelink certificates or driver licence forms.  

  • Did you understand the requirements in the document? Were there parts that were confusing? Where would you find information about filling in these templates?
  • How often would you review a workers’ compensation claim?
  • Was there a template in another patient's file that you could compare with the one you have prepared? How did it differ?
  • Where does the Fair Work Ombudsman fit in?

In your practice software, open a test patient and prescribe medications from the following classes: GLP-1 agonists for diabetes, GLP-1 agonists for ‘off-label’ use for weight loss, increased quantities of an SSRI, opioids, and proton-pump inhibitors. Review the prescribing requirements for ADHD medications relevant to your state or territory.

  • Did warnings come up on the system? Do you understand the PBS limitations that popped up on prescribing these medications?
  • Did your script include all the relevant information regarding dose and prescribing interval? Did you handwrite any of them?
  • Where would you find information about safe prescribing for medications?

Audit your notes, looking for care plans that have been completed and billed, or perform one on a test/trial patient. Another option is to do this activity for health assessments or Aboriginal and Torres Strait Islander health checks.

  • Did the documentation in the notes meet the MBS guidelines for claiming the item numbers? Was the correct item number claimed? Was consent from the patient documented? Was it done appropriately?
With a supervisor

With your supervisor, discuss safety within the practice, such as policies and procedures, that exist to ensure staff are safe (not only physical safety, but also from the risk of bullying or harassment). Some examples include managing cold chain issues for vaccines, and spills.

  • What will you take from this discussion to your ongoing practice?
  • Do you feel safe practising in your current practice? How will this inform how you look at future training locations?

Discuss the protocols in your practice for managing results, recalls and clinical record keeping.

  • How do you reduce risk and prevent missed results and recalls? How are urgent results checked? Is there a system to do this daily? What happens when a GP in training or practitioner goes on holiday or leaves the practice?
  • Who do you go to for information about practice processes?
  • What happens if a complaint is made?
  • What practice supports are available?
In a small group

Role-play a situation where a patient is requesting opioids or a Centrelink certificate in a way that does not meet guidelines or is not indicated.

  • How would you manage this consultation? How would you manage the patient’s concerns and expectations?
  • How would you de-escalate the situation if the patient gets agitated or aggressive?
  • How would you ensure you are up to date with their medical history and the regulatory requirements?

Discuss how you would manage a consultation with a child who you suspect is being abused by a parent.

  • How would you communicate with the parent?
  • How would you assess for signs of abuse?
  • As a group, discuss your responsibilities as practitioners regarding mandatory reporting and what your avenues are for support and guidance.
  • Did you meet your responsibilities as a practitioner in the role play?
With a friend or family member

Explain an advance care directive to a friend or family member.

  • Did you use regulatory frameworks?
  • What did you find challenging?
  • How would you manage this type of consultation in real life?
  • How do you assess competence for consent?
  • Ask your friend for feedback – did they understand your explanation? Ask them to tell you what they understood from what you said to them. How could you improve your communication? Are there areas of the topic that you need to learn more about so you can answer their questions?

Explain Medicare billing to a friend or family member. Include what bulk billing is, private billing, billing for long consultations and care plans.

  • Were you able to explain the requirements for Medicare billing for different item numbers, such as long consultations and care plans?
  • Did your friend have questions you couldn’t answer? Can they explain the process of Medicare billing back to you?
  • Where can you access information about MBS billing?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand and prescribe safely and responsibly, and with cost awareness:
    • Pharmaceutical Benefits Scheme (PBS) prescribing
    • Department of Veterans’ Affairs (DVA) prescribing
    • authority prescriptions
    • private prescriptions
    • extemporaneous/compounded medications and ‘off-label’ prescribing (risks and benefits)
    • drugs of dependence (S8)
    • medications under the Closing the Gap scheme
    • medications under the Special Access Scheme or Authorised Prescriber Scheme
    • over-the-counter medications
    • alternative medicines
    • alternatives to pharmacological therapy.
  • Be familiar with models of billing, including:
    • Medicare (knowledge of common item numbers)
    • DVA
    • private billing (including those covered by insurance providers other than Medicare, such as motor vehicle accident and work related, or not covered by Medicare, such as work medicals)
    • care plans and health assessments.
  • Complete certificates ethically and legally, including:
    • sickness
    • Centrelink
    • private insurance
    • work and capacity-for-work certification
    • fitness to drive
    • death and reporting to coroner and for cremation
    • order forms, including doctor’s bag medication.
  • Understand patient rights and capacity for consent for:
    • mature minors (Gillick competence)
    • the patient with reduced capacity to consent; for example, because of mental health, disability or dementia
    • confidentiality
    • involuntary admission to a psychiatric institution under a mental health act
    • medical power of attorney and guardianship
    • advance care directives
    • voluntary assisted dying
    • mandatory reporting:
      • child abuse
      • impaired health professional
      • communicable diseases
      • medico-legal reports and subpoenaed medical records.
  • Use practice quality and safety systems effectively to:
    • manage results
    • identify patients from an Aboriginal and Torres Strait Islander background
    • manage recall and reminder systems
    • ensure practice and individual quality improvement.
  • Maintain and use quality clinical records appropriately, including:
    • collect appropriate information
    • use templates appropriately for health assessments and Aboriginal and Torres Strait Islander health checks
    • develop accurate and legible recordings of consultations and referrals to enable continuity of care by GPs and other colleagues
    • have an appreciation of patient and practice information technology management requirements, medical records and legal responsibilities, and reporting, certification and confidentiality requirements
    • use the My Health Record platform
    • integrate medico-legal requirements into the clinical record (informed consent documentation)
    • generate medico-legal reports
    • respond to medical record requests and subpoenas.
  • Practise personal safety within the practice:
    • understand the practical aspects of safety: personal and physical safety – especially during consultations and for front desk staff – and safe practice cultures, including safe working environments, infection control and safe business practices.
  • Manage time efficiently in consultations.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Medico-legal and healthcare complaints are unfortunately common in practice. This article suggests strategies to reduce the effects before a complaint is made. What to think about in using social media for peer advice or informal input from colleagues.
Online resources
Important updates about clinical practice and item numbers; review this site regularly.
  • Australian Government Department of Health. MBS Online.
This is a handy tool for MBS fees that is useful to review regularly. Effective non-drug treatments for use in clinical practice. A guide to improve the quality and safety of prescribing drugs of dependence. Helpful information to manage billing, including billing calculators, MBS tools and tips on discussing fees with patients. There is also a business toolkit to help GPs establish and manage their practice, including modules and webinars.
Modules

Learning this core unit is best done through case-based learning. The RACGP gplearning website and CPD website have excellent resources; some of these are:

  • Ethical and legal considerations in general practice MCQs
  • GP Pathway to Australian general practice
  • Medico-legal complexities of managing people with AOD concerns
  • Travel medicine, infectious diseases and WorkCover
  • My Health Record - A practical demonstration
  • Opioid deprescribing and withdrawal management
  • Chronic disease management: MBS items in aged care.
Excellent webinars and clinical courses on evidence-based prescribing. This site is independent of pharmaceutical company input.
Other
The Royal Australian College of General Practitioners.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/domain-5 27/09/2022