5.1 Clinical correspondence
5.1 Internal and external clinical correspondence
Clinical correspondence refers to any patient information received from or sent by a doctor or health organisation, which relates to an individual patient’s clinical care.
|Standard - what we'll be assessing on||Evidence to provide for assessment|
The practice effectively manages internal and external clinical correspondence.
Clinical correspondence refers to any patient information received from or sent by a doctor or health organisation, which relates to an individual patient’s clinical care. Clinical correspondence includes laboratory results, imaging reports, significant investigations, clinical correspondence (for example, letters and discharge summaries) and urgent referrals.
Significant tests and urgent referrals
Clinically significant results are defined as those having a significant impact on the healthcare of a patient and may include either normal or abnormal results. Where significant pathology is suspected the ordering practitioner must track the result to ensure that the patient has completed the test and the result has been received. It is important that there is a standardized process across the practice team for the tracking significant results and urgent referrals which includes timeframes and methods of patient notification.
Managing patient test results in general practice is a complex task. It involves all members of the practice team, relies on the systems in the general practice and the outside provider, and requires the results to be communicated to the patient in a timely, clinically appropriate and meaningful manner.
The highly administrative nature of test result management can feel bureaucratic at times, but it is a critical part of a patient’s diagnostic work-up and the results often have significant implications for the care patients receive.
The complexity involved means that errors can occur, and these have sometimes resulted in patient harm.
A reliable and practice wide agreed process for recording and managing clinical investigations enables correct tracking and management.
It's imperative patient reports are not lost in the system and are processed to ensure the right people get the right information within the time frames identified by the practice. For every report or test there must be a person in the practice responsible for management and tracking.
Auditing the practice’s processes
Any medical investigations requested by the practice must have a clear pathway to an outcome (request, results, communicate results, record results, patient informed, action taken, dated, time limit identified).
Auditing these processes allows the practice to see where improvements can be made. Key areas to focus on:
- Identify missing results, i.e. not received from the laboratory, or ordered but information not complete.
- Provide information about the status of medical investigations that have been returned to the practice.
- Appoint a clinical team member responsible for monitoring the review and action of all incoming tests, results and medical reports (see clinical governance below).
- Appoint a designated deputy, for example a locum, to process the reports if that requester is not available or is on leave.
- Track specialist referrals.
Tracking methods may include:
- Automated electronic ‘flag’ to alert the requester at an identified period.
- Automated electronic ‘task’ to direct the requester to investigate receipt of results at an identified period.
The practice must allocate responsibility of all clinical correspondence to make sure it has been actioned. Some practices have one team member (e.g. senior clinician) who reviews all inboxes and outstanding items, others delegate the responsibility across team members. This can also be a regular agenda item at clinical governance meetings. It is key that issues are monitored and addressed quickly.
Practices will not ordinarily be held liable for lapses in care or communication by an individual practitioner who they ‘employ’. However, if the lapse was attributable to poor systems or inadequate protocols at the practice, the practice may be held vicariously liable. General practices must have good, robust systems in place, provide appropriate training, guidance and support, and ensure ongoing audit and review.
Under the Health and Disability Commissioner Act 1994, ‘employing authorities will avoid vicarious liability if they can show that they took such steps as were reasonably practicable to prevent the acts or omissions that amount to a breach of the Code of Health and Disability Services Consumers’ Rights.’
Clinical correspondence and investigations policy and procedure
A documented Clinical Correspondence and Investigations Policy and Procedure must include:
- A process for managing all types of clinical correspondence, for example, laboratory results, imaging reports, significant investigations, clinical letters and urgent referrals.
- Team roles and responsibilities
- Clinical oversight (senior GP)
- Time frames for acting on/communicating results
- How communication with patients about test results are documented.
- Method of notification
- Urgent referral and significant investigations/tests management
- how clinical correspondence is managed when practices are operating alternately, for example, practitioners working remotely from home in cases of pandemics or other situation
- Safety netting
- Auditing the process.