Referrals and recalls

If the doctor has felt it important to refer a patient to another practitioner, then they need to be aware of the outcome of that referral. Developing a tracking system that records referrals and returned reports will identify any patients who do not present for appointments with practitioners to whom they have been referred.

There are specific government requirements regarding patient referrals and these must be complied with if patient claims are to be made through Medicare.

As a practice manager, you can use a recall system to track ‘at-risk’ patients who the doctor/s have asked to return for clinical review.

The doctor should explain to their patient the reason for a referral and whether or not it is urgent. This advice should be documented in the patient record.

Discussion of the patient’s expectations of the referral outcome and arrangements for continuity of care should also take place. The referring medical practitioner should include the following as a minimum in their referral letter:

• patient personal and contact details
• patient occupation
• relevant patient social history
• relevant patient medical history, including current medications, allergies, past and current medical conditions
• relevant test results
• reason for referral

Determine which referrals will require tracking by considering the following:

• The patient’s condition - is it serious or life-threatening?
• The risks to the patient of either delaying or not attending the referral appointment.
• Whether diagnostic tests were abnormal.

What steps reasonably ought to be taken in fulfilment of this duty of care, which will depend on the magnitude of the risk of an adverse outcome.

How following up a specialist referral for a potentially serious condition may reasonably be more than for a less serious condition (urgent referral to a cardiologist re: recent sub-acute cardiac symptoms compared to referral to an orthopaedic surgeon for osteoarthritis of the knee).

Where a patient declines to attend a specialist, it is advisable to document that you have explained to them the consequences of non-attendance.

The system you adopt to ensure that patients are followed up when referred should:

• be simple enough that it does not impose an onerous task on staff
• be effective enough that a patient who needs to be seen does not slip through the system
• be easily managed via your computer software or via manual system (refer to referral tracking spreadsheet).

Some of the principles discussed in the previous section on test tracking will assist this process. Please also consider the following points:

• If a referral is considered urgent, make the appointment for the patient yourself to ensure it gets done.
• If you deem it necessary to make the appointment for the patient, details of the appointment should be recorded in the patient’s notes.
• Have discussions with patients on the importance/urgency of the referral to be documented in the patient notes.
• Develop a centralised referral tracking system similar to the test tracking system discussed previously. This will assist in checking correspondence has been received from the specialist or practice to which the patient was referred. It will help to ensure patient compliance. You may create an ‘urgent recall’ reminder (set at a nominated period e.g. – seven days) for use in the clinical software.
• If the reason for referral is less urgent, you can track patients by marking them as a ‘recall’ for a date that you would expect some feedback from the referral. Perhaps your computer software could send you a reminder at the next patient attendance.
• Letters of referral to medical specialists or consultant physicians need to comply with government regulations (see Medicare Benefits Schedule Book). The Medicare compliance program www.humanservices.gov.au/healthprofessionals has information for doing business with Medicare.
• All referrals need to be current and staff need to check the currency of referrals before the patient attends the practice referred to.
• Referrals for pathology or radiology tests need to comply with government regulations. (See Medicare Benefits Schedule Book). Contact the pathology or radiology company for relevant referral stationery or availability of electronic referrals.
• Procedures for referrals and recalls should be documented in the practice’s procedure manual and all staff should be appropriately trained.
• Use a date stamp for all incoming referral letters.

Where specialists advise a referring practitioner of a patient’s failure to attend an appointment:

• Some referring practitioners will forward a referral to a specialist before the patient has made an appointment.
• It is important to have a triage process in place to ensure a timely appointment is provided to the patient.
• Where referrals are received but where no appointment has been made, it should be returned to the referring practitioner after the specialist has assessed a reasonable time has passed since receipt of referral.
• When a patient does not present for a referred appointment or has cancelled an appointment the specialist must provide this information to the referring practitioner to ensure continuity of care is appropriately provided.
• If a patient refuses for their normal treating medical practitioner to be provided with feedback about a consultation, such as the case when a patient is reviewed by a skin cancer clinic; request the patient signs a form refusing information to be provided to the normal medical practitioner.

The operation of a recall system is straightforward once a manual or computerised system is set up. The success of the recall system is dependent on you flagging the patient for recall during consultation.

As the practice manager you can manage the mail-outs to recalled patients, or alternatively, this can be managed by a registered nurse who is responsible for monitoring the patients who require recalls.

Letters are often printed on a monthly basis and reviewed and signed by the practitioner or by a nurse/nominated staff member on behalf of the practitioner before posting. Depending on volume, you may consider printing twice monthly.

If you use a manual recall system, you can initiate it by annotating a stamp on the patient file. The patient’s file can then be forwarded to the staff member responsible for monitoring the manual recall system who records the recall for the appropriate month in a central location/book.

It is important to ensure that you document all attempts to recall your patients. A copy of each letter sent should be kept on the patient's file, including whether it was sent by registered mail. Any telephone contact or messages left should be documented in the patient's file with the relevant date and time of call, the name of the person who made the call and any action taken.

It may be convenient to SMS patients who are due for recalls. However, clinical information should not be included in the SMS. Patients should provide consent to an SMS recall system.

Patients have the right to not partake in a recall system. The patient’s express wishes to not partake should be documented in the patient record.

For significant follow up or recalls a minimum of 3 attempts to contact the patient should be made. This can include 2 phone calls, letters or combination of both. The final contact should be by registered letter which is signed by the patient as received. Include in the registered letter written information to support the patient’s understanding of the clinical significance of following up the suggested follow-up/recall. Document the above in the patient record