It’s a busy morning in the clinic. A patient who had a 10.30am appointment does not attend. What are the possible implications if neither the clinician nor practice staff take any action regarding the missed appointment? For repeat appointments, the practice staff will be in a better position to identify cases where action is essential and in the patient’s best interests.
They may be able to triage the situation into various categories:
The situation is more complicated if the patient has never been seen before. This is especially so for specialist practices. Specialists have often already received test results or other information indicating a degree of clinical seriousness. A common example is an abnormal pap smear, where the patient fails to attend. Under this circumstance it is essential for the specialist to let the referring GP know of the non-attendance.
You have a duty to exercise reasonable care and skill in the treatment of patients. Administrative staff also have an obligation to exercise reasonable care. This duty extends to the examination, diagnosis and treatment of the patient, the provision of information and follow-up.
Case law regarding patient follow-up has centered on follow-up of tests, and suggests that once you have undertaken tests or recommended a procedure or test, then – for the duration of your relationship with the patient – you have a duty to:
There is also case law outlining the responsibility of a referring doctor to follow up referrals to specialists.
Many practitioners feel that the onus of responsibility on them is too great and that the courts have inappropriately shifted patients’ responsibilities to the practitioner. This may be a genuine feeling but it has limited sympathy in law. It is important to note, however, that the principles underpinning the case law in this area have been captured in College standards and Australian Medical Association (AMA) position statements.
The RACGP [Royal Australian College of General Practitioners] Standards for General Practices outline a practice’s responsibilities for follow-up of clinically significant tests and results. Clinically significant refers to:
The AMA position statement on patient follow-up and tracking, in section 2.3, Patient Follow-Up, Recall and Reminder Systems, includes the following recommendations for care:
Most GPs now use some form of electronic medical record and practice management system. This has enabled very convenient and reliable recording of patients’ appointments and easy identification of non-attenders. It has also enabled staff to look regularly at a list of outstanding recalls. Unfortunately, errors still occur because of human factors in understanding and using the software.
Strategies to manage this risk include:
Clinically significant referrals should be systematically tracked. When a letter or phone call is received from the specialist, the referral is taken off the list. The list can then be periodically reviewed for any outstanding referrals.
As the practitioner, you have an obligation to fully explain why follow-up is required. Patients may not understand the significance of the need to see another practitioner or have more tests and may dismiss the request. You must make it clear why something must occur, using an interpreter as necessary.
Consider approaching this part of the consultation in the same way as a consent process. By informing the patient of the need for the tests, your concerns, the reasons for and the risks associated with not attending the referral or a follow-up appointment, you pass the responsibility and the choice to the patient. This process and documenting the advice given (for example, explained need for tests to rule out ‘X’. Come back for results in (two weeks) will assist in defending an allegation of the failure to follow up.
All attempts at follow-up need to be documented in the patient’s medical record. Documentation of phone calls should include the date and time of the call, the name of the person who made the call, any message given and any action taken.
Copies of letters sent should be included in the record, and notations made where letters are sent by registered mail. Missed appointments should also be clearly documented in the records. The appointments system should allow a permanent record of all cancellations and failures to attend.
Proactive systems can help prevent missed appointments: