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 unsure whether patient privacy considerations place any limits on the actions they can take to follow up with patients. This uncertainty may lead to a missed or delayed diagnosis or other issues for the patient, where recommended investigations are not undertaken, referrals not attended to, or test results are not communicated.

Doctors 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. The extent of follow up required will depend on the clinical significance of the test or referral, and this will differ from patient to patient.

You are not expected to chase a patient over every routine test or follow up non-urgent issues where you have no ability to control or influence the outcome (for example, referral of a patient with a non-life threatening condition to a public hospital).

However, if a proposed test, investigation or referral is likely to be clinically significant, you are expected to follow up with the patient. Whether something is clinically significant involves an assessment of:

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

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, results and referrals. 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 – in particular, clinically significant results or reports that were not received within a specified timeframe
• whether results or reports 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. Make sure everyone working in the practice, including clinical and non-clinical staff and temporary staff, locums and registrars, understand the processes in place and their role in these processes.

It would be too onerous to track all outstanding requests for results but, in addition to practice systems, you may consider making a specific note or adding a recall for yourself for any particularly clinically significant requests. This can be done at the time of documenting your discussion with the patient about the importance of following through with the investigation.

From a data perspective ensure that there is a back-up system in place - in case data is lost, the system is hacked into or there is a natural disaster such as a fire or flood.

For general practices, the RACGP Standards for General Practice (5th edition) outline in more detail the expectations for managing results. For non GP-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 investigations, referrals and results are not overlooked. Problems can arise due to misunderstandings about the urgency of tests, investigations and referrals, or how results will be communicated.

When you recommend a test, investigation or referral ensure the patient understands:

• the reason for the test/investigation, referral or follow-up appointment
• why it is important and the potential consequences of not following your recommendation
• 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. Document the discussed steps and management plan in the clinical notes for the consultation.

Patients are entitled to decline to follow advice about further investigations and referrals. These discussions or decisions should also be documented.

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 your practice has a clear policy about notifying results to patients and that all staff involved in managing the recall system are aware of the steps to be taken. Be clear about individual responsibility and timeframes for acting on urgent results and who can notify patients of their results. Consider how you will communicate significant 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 clinicians 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, this does not change your responsibility to follow up results and recall patients. The patient will be able to access the results seven days after they are uploaded. You are not obliged to check My Health Record for any results you have not ordered and are not aware of.

Standard steps for follow-up 

The steps you need to take to follow up a patient depend on their circumstances and clinical situation, including the potential harm if there is any delay in communicating the results.

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, for example if the practice is a fertility clinic or a sexual health clinic.

If none of these methods work

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.

If the result is urgent and a potential emergency, 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 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, you could check with the patient whether they have received the results.

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