The doctor-patient relationship is the bedrock of medical practice. This relationship requires not only careful communication in consultations but also diligent follow-up communication outside consultations. Patient recalls and reminders are essential to the continuity of care, health maintenance and patient safety.
Medical practitioners are obligated to ensure that results from all tests they have ordered are appropriately followed up with their patients. Medical practitioners need to base their recall efforts on the clinical significance of the result.
‘A chest X-ray that shows evidence of previously undiagnosed lung cancer is a very clinically significant result. In such a situation it is appropriate practice that the patient is urgently recalled with ongoing attempts to recall the patient with letters (including registered letters) until the patient is aware of the result and their options for treatment.’ Dr Martine Walker, Medical Advisor at the Medical Council of NSW, said. ‘A mildly abnormal cholesterol, however, although clinical significance is less urgent. This may require only a non-urgent recall call or letter or a reminder placed in the record in a way that all practitioners in the practice can see that this result needs discussion at the next visit.’
Patient communication when a test or referral is suggested is also vital. It is important to make sure the patient understands why you are ordering the test or making the referral and what risks they would be taking if they didn’t act on that referral. e. g when referring a woman with a concerning breast lump for imaging, it is important to make sure the patient understands you are recommending the referral to help rule out cancer.
When recommending a test or making a referral it is also important to explore any barriers a patient might have such as geography or expense. ‘If the patient does not have the appointment or test you recommend it's vital to explore why it hasn’t happened and the barriers preventing them from doing it. Ask if you can help in any way e.g. calling to make the appointment. If they couldn’t afford it, offer to look at a different affordable option.’ Dr Walker said.
A quick “pre-consultation” consultation before seeing a patient is really useful to remind you about past issues, tests or referrals that may still be pending. Dr Walker suggests that: ‘When you are about to see a patient, spend a bit of time going back through their file. What happened at the last appointment? Is there anything that has been missed? Are there tests that haven’t been addressed yet? Are there recalls that have not been acted on?’
A reminder involves a situation in which a patient is reminded that a recommended investigation or procedure is due to be performed. It’s part of preventative care and a proactive way of promoting health care to patients. There is no legal requirement for general practices to send reminders to patients about routine tests.
‘A reminder might be something like ‘Get your cholesterol checked, or you’re due to have your diabetes checkup’ and they’re important in terms of good quality care rather than patient safety.’ Dr Walker said.
A foolproof system
Criterion GP2.2 on page 126-131of the RACGP Standards for General Practices 5thEdition focuses on the systems that general practices need to follow up tests and results. It states that ‘The follow-up system needs to be designed in a way that anticipates individual cases will require a different level of follow up depending on the clinical significance of the case…’. When it comes to managing patient recalls and reviews, it’s important to have a system that can reliably track and record what is happening with patient referrals and reminders.
‘The system needs to be foolproof. It doesn’t have to be a complex electronic system and can be as basic as a notebook. Whatever system you use you need to have a system you can rely on to continue to work if you are not available and means patients’ abnormal results will be followed up. Ideally, you want everyone in your practice to be using the same system so that things don’t fall between the cracks.’ Dr Walker said.
There are also legal reasons for ensuring your records are in order. ‘If your records show you have adequate systems of recall and you’ve done everything you would be expected to do, you are legally in a good position. It’s hard to defend failure to act on a clinically significant abnormal result when you haven’t taken the appropriate steps of recall.’ Dr Walker said.
Systems need to be chosen for their suitability to the individual practice. According to Dr Walker, ‘There’s no one size fits all. Each practice will do it in its way. As long as it covers the purposes of recalling and ensuring patients are aware that you are recalling them for clinically significant abnormal results. It’s a little bit like COVID-19 - you can’t have a chink in the armour, If there is a break in the chain of protection, patients are put in danger.
The Medical Council of NSW would like to thank Dr Sara Bird, Executive Manager, Professional Services at MDA National for her expert advice on this story.