Patient follow-up and recalls

• Actively follow up any results, referrals or reports that are likely to be clinically significant.
• Have processes that allow tracking of results that are missing as well as those received.
• When referring a patient for investigations, also confirm how you will follow up results.

Doctors are often unsure how far they need to go in following up patients for return appointments, review of test results and specialist referrals. They may also be concerned whether any patient privacy concerns limit the steps they can take to follow up patients. This uncertainty may lead to a missed or delayed diagnosis or other issues for the patient, where recommended investigations are not undertaken, or test results are not communicated.

Practitioners often ask whether they need to follow up all test results and referrals. You are expected to take steps to make sure that investigative tests or referrals are acted upon appropriately and the results communicated in a timely manner.

Patients are entitled to decline to follow advice about further investigations and you are not expected to chase a patient over every routine test result. However, if patients fail to have tests or investigations you have recommended, or to return to receive results, you are expected to make a reasonable attempt to follow up investigations that are likely to be clinically significant. This would involve an assessment of:

• whether the patient’s condition is potentially serious or life-threatening
• the risks to the patient of delaying or not having the test or attending the specialist appointment
• the significance or abnormality of any results or reports.

One key to ensuring appropriate follow-up is having an effective system that allows for different levels of follow-up, depending on the clinical significance of the test and/or results. It should allow you to track:

• when a clinically significant investigation is ordered, or referral written
• when results or reports are received in the practice
• whether results have been reviewed and clinically significant results actioned (including patients being recalled or advised of the results) within appropriate timeframes
• any missing results – i.e. clinically significant results or reports that were not received within a specified timeframe
• whether results have been incorporated into the patient record.

Ensure your systems and processes address scenarios such as how results will be checked when doctors are away or no longer working in the practice. These are common situations where results can be overlooked and problems arise. Make sure everyone working in the practice, including temporary and locum staff and registrars, understand the processes in place and their role in these processes.

For general practices, the RACGP Standards for General Practice (5th edition) outline in more detail the expectations for managing test results. For specialist practices the RACGP standards are useful in guiding appropriate systems to implement in your practice.

Confirming contact arrangements

Your practice processes should include regularly checking the patient’s contact details to make sure they are current, including confirming with the patient how to best contact them if necessary. For more information please see Avant’s factsheets: Recommendations when using SMS messaging and Email communication with patients.

Communication with your patient is an important element in ensuring significant test results are not overlooked. Problems can arise due to misunderstandings about the urgency of tests, or how results will be communicated.

When you recommend a patient has a significant test or sees a specialist for investigation, ensure they understand:

• the reason for the test
• why it is important and the potential consequences of not having it done
• how urgent it is or when they should expect to get an appointment
• how they can expect to get the results – should they call, make a follow-up appointment, expect a call or message from the practice?

This conversation is an opportunity to set the patient’s expectations, clarify their understanding and also discuss any proactive steps if a timely review is needed. Include the steps discussed and the plan in the clinical notes of the consultation.

Processes for communicating results to patients need to take account of the clinical significance of the results and whether or not the results were as expected.

Again, it is essential that all staff involved in managing the recall system are clear on the steps to be taken. Be clear about responsibility and timeframes for acting on urgent results and who can notify patients of their results. Consider how you will communicate unexpected results to a patient. For more guidance please see Avant’s factsheet Breaking bad news to patients.

It is also important to confirm with any other practitioners involved in the patient’s care how results will be communicated, and by whom.

If results are uploaded to a patient’s My Health Record, your responsibility to follow up results and recall patients is unchanged. The patient will be able to access the results seven days after they are uploaded.

Standard steps for follow-up

If you need to recall a patient for a significant clinical reason, the appropriate procedure should take account of the patient’s circumstances and the clinical situation, including the potential harm to the patient in light of the results. This will guide the number and frequency of attempts to contact the patient and the different ways used to contact them.

Steps may involve:

• telephone calls at different times of the day to the patient’s preferred contact number
• contacting the patient by SMS, by mail and/or email to the address in the patient’s record.

Make sure that all attempts to contact the patient are documented in the patient’s record.

Leaving messages for a patient

Always take care with any messages you leave. If the patient has provided a direct phone number for contacting them, it is reasonable to leave a message on that phone number asking the patient to call the practice.

If the results are sensitive and/or the patient is a young person or is vulnerable it may be appropriate to leave only your name and not the name of the practice.

What if none of these methods work?

If the previous methods have been unsuccessful, and if clinically warranted, we recommend a further step of sending a registered letter to the patient. The letter should reiterate the importance of the test or investigation and risks of not proceeding with the recall, referral or test. Keep a copy of this in the patient’s record and ensure you also track whether the letter was delivered and document this in the clinical record.

In some situations, when the result is considered urgent, you may need to take further steps to ensure the patient is notified. This will depend on the circumstances and may include contacting a family member, visiting the patient’s address or notifying police if there is a serious threat to life, health or safety. If you are considering this option seek advice from your professional college or Avant.

You may become aware of test results ordered by other practitioners. Generally, the practitioner ordering tests is also responsible for following up the results, unless otherwise agreed. However, if you receive clinically significant results that you have not ordered for one of your patients, it is good practice to contact the ordering practitioner and check with them about the arrangements for communicating with the patient. Alternatively, it may be appropriate to check with the patient whether they have received results.

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.