CG6 – Follow-up systems

The information obtained from investigations can affect the choices that a patient, the GP, and other clinicians make about the patient’s care. Clinically significant results need to be communicated quickly and appropriately so suitable action can be taken to reduce the likelihood of an adverse patient outcome.

Recall refers to the process of requesting a patient to attend a consultation to discuss significant clinical matter/s. Failure to recall a patient may result in an adverse outcome and the responsible practitioner may face medico-legal action.

Reminders are proactive prompts given to patients to visit their practice for routine or important tasks related to their health. Using reminders will mean that patients are more likely to, for example, return to the practice to undergo a preventive activity such as cancer screening.

The practice needs to have systems to support the timely review, management and documentation of clinical information received about its patients.

Responsibility for reviewing incoming clinical information needs to be clearly allocated, including arrangements for cover when the requesting GP is unavailable. Clinical information needs to be directed to the appropriate clinician without delay.

The practice could use systems that support members of the clinical team to:

• review incoming clinical information
• record review and actions taken (for example, through electronic notation, or signature/initialling where information is received in paper form)
• act on information where required
• incorporate clinical information into the patient health record.

The practice needs to have processes to:

• identify and follow up clinical information that has not been reviewed or actioned
• follow up investigations and results that have not been received.

Actions taken in response to clinical information, including any required follow-up, need to be documented in the patient health record.

These processes support the timely review and management of clinical information and reduce the risk of missed or delayed care.

A recall occurs when a patient needs to be reviewed within a specified period. For example, the practice might recall a patient on behalf of a member of the clinical team:

• to discuss a clinically significant investigation result
• to discuss a report received from a specialist
• after diagnosis of a significant condition
• for medication management, particularly where missing a review could have a significant consequence (for example, missing a long-term injectable medication).

To help make sure that clinical information is appropriately reviewed, notated, acted on and documented in the patient’s health record, the practice could:

• provide clinicians with remote access to the clinical software
• use secure electronic platforms to issue recalls.

The practice’s recall process could include:

• a policy or other document outlining how patients are followed up regarding recalls, including:
  • the roles and responsibilities of different members of the practice team in relation to recalls
  • how results and recalls are communicated to patients (for example, phone calls or text messages)
  • the number, frequency and nature of the attempts the practice will make to contact the patient (for example, up to three telephone calls at different times of the day followed by an email, text or letter), based on the practice setting
  • what information different members of the practice team can convey and how to convey it (if reception staff are responsible for making an appointment for patients with clinically significant results, they need to know the suitable type of language to use in such a conversation)
  • how to consistently document each contact with the patient in their patient health record
  • the actions the practice will take if the patient:
    • does not respond to recall notifications
    • is not notified of an outstanding result during a consultation regarding an unrelated matter.
• recommendations about what information needs to be recorded (for example, clinical discussions and outcomes) in patient health records
• how the practice ensures tests and results are reviewed and acted upon in a timely manner.

For patients who may be at risk, the practice needs to use discreet or privacy‑sensitive recall methods, including verifying preferred and safest contact channels before sending reminders or follow‑up messages. When follow‑up is required but the patient cannot be contacted, the practice needs to document attempts in a way that does not escalate any known or suspected risks (for example, avoiding detailed messages if voicemail or SMS may be accessed by others). If follow up is required outside normal opening hours, the practice could provide general information about appropriate afterhours or crisis support services.

Reminders are used to help manage preventive care by noting in a patient’s health record when the patient is due to return to the clinic for a routine check, for example, the practice could message patients who are:

• in high-risk populations for vaccine preventable diseases (for example, children, patients who are immune-compromised, older people)
• eligible for national cancer screening programs.

The practice’s process relating to non-clinically significant reminders could address how (or whether) they are followed up or recorded if the patient does not respond to a reminder.

The practice could:

• appoint a member of the practice team to be responsible for managing recalls and reminders
• have reminders automatically sent via the clinical information system
• have templates in the clinical information system for standard correspondence to automatically be sent via text or email when a reminder is triggered
• educate members of the practice team so they can tell patients about the reminder process
• publish the reminder process on the practice’s website.

The practice needs to have a policy to describe its processes for high-risk results that are identified outside of normal opening hours. This includes advising its main diagnostic services of appropriate contact details to communicate high-risk results to the referring GP or their delegate outside of normal opening hours. This contact information includes the requesting GP’s phone number or contact information for the after-hours and medical deputising service (AHMDS). The practice must ensure that whichever contact is listed can reliably undertake timely communication and action when a high-risk result is identified.

If the practice engages an AHMDS, it is recommended that the practice explains to deputising doctors what is expected of them if they receive urgent and life-threatening results for one of the practice’s patients. The deputising doctor has a responsibility to:

• contact the patient outside normal opening hours if necessary
• inform the general practice the following day.