policy and procedure practice manual · web viewfollow the procedures listed above in booking an...

The following template policies and procedures are based on the requirements of the

RACGP Standards for General Practices (4th Edition)

TABLE OF CONTENTS

1. SCHEDULING CARE IN OPENING HOURS (CRITERION 1.1.1)........................................11.1. Scheduling patient appointments.........................................................................................1

1.1.1. Booking an appointment..................................................................................................21.1.2. Rescheduling an appointment – changed by a patient....................................................21.1.3. Rescheduling an appointment – changed by the practice...............................................21.1.4. Recording missed appointments.....................................................................................31.1.5. Cancelled and missed appointment fees.........................................................................4

1.2. Triage...................................................................................................................................51.3. Emergency telephone call with doctor present.....................................................................61.4. Emergency telephone call and no doctor present................................................................71.5. Emergency patient presents to reception with doctor present.............................................71.6. Emergency patient presents to reception and no doctor present.........................................81.7. Patient discomfort in waiting room.......................................................................................91.8. Dialling emergency ‘000’......................................................................................................91.9. Subsequent action following an emergency or exceptional situation.................................101.10. Referring important information to the general practitioner................................................101.11. Length of consultations......................................................................................................111.12. Patients with special needs................................................................................................111.13. Practice closures................................................................................................................121.14. Visitors................................................................................................................................122. TELEPHONE AND OTHER COMMUNICATIONS (CRITERION 1.1.2)...............................132.1. Telephone communication.................................................................................................13

2.1.1. Telephone techniques...................................................................................................142.1.2. Answering incoming calls..............................................................................................152.1.3. Placing callers on hold...................................................................................................152.1.4. New patients..................................................................................................................162.1.5. Telephone requests for referrals....................................................................................162.1.6. Telephone requests for repeat prescriptions.................................................................172.1.7. Telephone requests for results......................................................................................182.1.8. Taking messages...........................................................................................................192.1.9. Clinical messages..........................................................................................................202.1.10. Outgoing calls................................................................................................................212.1.11. Handling difficult patients...............................................................................................22

2.2. Electronic communication..................................................................................................232.3. Telephone and electronic equipment.................................................................................23

2.3.1. Telephone functions......................................................................................................232.3.2. Telephone problems......................................................................................................242.3.3. Email..............................................................................................................................24

2.4. Fees for telephone and electronic communications...........................................................243. HOME AND OTHER VISITS (CRITERION 1.1.3)................................................................253.1. Providing safe and reasonable care...................................................................................25

3.2. Access to alternative sources of care.................................................................................253.1. Who can perform home or other visits...............................................................................263.2. Safety of health professionals............................................................................................274. CARE OUTSIDE NORMAL OPENING HOURS (CRITERION 1.1.4)..................................284.1. Options for care outside normal opening hours.................................................................284.2. Formal after-hours agreements..........................................................................................294.3. Follow up of tests taken during after-hours care................................................................294.4. Who can provide after-hours care for the practice.............................................................304.5. Communicating our after-hours arrangements...................................................................305. PRACTICE INFORMATION (CRITERION 1.2.1).................................................................315.1. Practice information sheet..................................................................................................315.2. Advertising practice information.........................................................................................315.3. Practice website.................................................................................................................325.4. Practice services................................................................................................................325.5. Practice hours.....................................................................................................................326. INFORMED PATIENT DECISIONS (CRITERION 1.2.2).....................................................336.1. Providing appropriate and sufficient information to patients...............................................336.2. Informing patients of potential treatment costs...................................................................336.3. Patient-doctor collaboration................................................................................................347. INTERPRETER AND COMMUNICATION SERVICES (CRITERION 1.2.3)........................357.1. Patients of foreign background and ethnicity.....................................................................35

7.1.1. Translating services.......................................................................................................367.1.2. Using friends and relatives as interpreters....................................................................37

8. COSTS ASSOCIATED WITH CARE (CRITERION 1.2.4)...................................................388.1. Fees for services and billing practices...............................................................................38

8.1.1. Private billing.................................................................................................................388.1.2. Bulk billing......................................................................................................................398.1.3. Department of Veterans Affairs.....................................................................................408.1.4. Workers compensation..................................................................................................418.1.5. Medical examinations not covered by Medicare............................................................428.1.6. Pre-employment medicals.............................................................................................42

8.2. Costs of other health services............................................................................................439. HEALTH PROMOTION AND PREVENTATIVE CARE (CRITERION 1.3.1)........................449.1. Health promotion activities.................................................................................................449.2. Preventative care................................................................................................................45

9.2.1. Vaccination and occupational health clinics..................................................................459.2.2. Mole scan unit................................................................................................................459.2.3. Asthma awareness........................................................................................................459.2.4. Seasonal ‘flu clinics.......................................................................................................46

9.3. Health risk assessments....................................................................................................479.4. Managing patient information to support preventative care...............................................479.5. Clinical resources for the practice – preventative health....................................................4810. CONSISTENT EVIDENCE BASED PRACTICE (CRITERION 1.4.1)..................................49

10.1. Clinical practice guidelines.................................................................................................4910.2. Clinical resources for the practice – evidence based practice...........................................5010.3. Patient identification – prior to surgery...............................................................................5110.4. Health inequalities..............................................................................................................5210.5. Consistent communication.................................................................................................5311. CLINICAL AUTONOMY FOR GENERAL PRACTITIONERS (CRITERION 1.4.2)..............5411.1. Clinical autonomy within evidence based care...................................................................5411.2. Professional and ethical obligations...................................................................................5412. CONTINUITY OF COMPREHENSIVE CARE AND THE THERAPEUTIC RELATIONSHIP (CRITERION 1.5.1)......................................................................................................................5512.1. Provider continuity and patient outcomes..........................................................................5512.2. The doctor patient relationship...........................................................................................5612.3. Courtesy notifications.........................................................................................................5612.4. Supporting preferred relationships.....................................................................................5713. CLINICAL HANDOVER (CRITERION 1.5.2)........................................................................5813.1. Defining clinical handover..................................................................................................5813.2. Clinical handover actions...................................................................................................5913.3. Transfer of patient health information to another practice..................................................6013.4. Transfer of patient health information – from another practice...........................................6013.5. Errors in clinical handover..................................................................................................6114. FOLLOW UP OF TESTS AND RESULTS (CRITERION 1.5.3)...........................................6214.1. Definitions...........................................................................................................................6214.2. Essential follow up systems...............................................................................................6314.3. Receiving incoming results and reports.............................................................................6414.4. Conducting a review of follow up systems.........................................................................65

14.1.1. The general practitioner and the reminder system........................................................6614.1.2. Practice staff and the reminder system.........................................................................6614.1.3. The general practitioner and the recall system..............................................................6714.1.4. Practice staff and the recall system...............................................................................67

14.5. Issuing recalls.....................................................................................................................6814.6. Reminders..........................................................................................................................6914.7. Errors in follow-up...............................................................................................................7014.8. Sending letters to patients..................................................................................................7015. ENGAGING WITH OTHER SERVICES (CRITERION 1.6.1)...............................................7115.1. Patient resources................................................................................................................7115.2. Staff resources...................................................................................................................7115.3. Location of resources.........................................................................................................7216. REFERRAL DOCUMENTS (CRITERION 1.6.2)..................................................................7316.1. Unique patient identifiers....................................................................................................7316.2. Sufficient information..........................................................................................................7416.3. Disclosure of patient information........................................................................................7416.4. Telephone referrals............................................................................................................7417. PATIENT HEALTH RECORDS (CRITERION 1.7.1)............................................................7517.1. Dedicated patient health records........................................................................................75

17.1.1. Creating a new medical record......................................................................................7617.1.2. Retention of records and archiving................................................................................7617.1.3. Destruction of medical records......................................................................................7717.1.4. Collecting information from patients..............................................................................7717.1.5. Recording cultural background......................................................................................7817.1.6. Recording Aboriginal and Torres Strait Islander status.................................................78

18. HEALTH SUMMARIES (CRITERION 1.7.2)........................................................................7918.1. Health summaries for safe and high quality care...............................................................7918.2. Coding................................................................................................................................7919. CONSULTATION NOTES (CRITERION 1.7.3)....................................................................8019.1. Consultation notes..............................................................................................................80

Chapter one: Practice services

1. SCHEDULING CARE IN OPENING HOURS (CRITERION 1.1.1)

Policy

Our practice provides timely care and advice to our patients.

Our practice has a flexible system that enables us to accommodate patients’ clinical needs.

1.1. Scheduling patient appointmentsPatients are given an appointment with the doctor of their choice wherever possible and advised of the availability of other doctors at this time. Under normal circumstances, a patient can expect to see their doctor (or an alternative as approved) within two working days.

Walk in patients may see the next available doctor if there are less than six appointments for that hour. Practice staff should advise them of the approximate waiting time and that patients with an appointment will be seen first.

Our staff are vigilant of the need to detect and place urgent calls for immediate or earlier attention by a doctor. Patients unable to attend the practice are able to have a home visit.

Our practice manager will review the appointment schedule regularly to ensure that it remains correct and up-to-date. The appointment book is reviewed for:

Clerical errors

Change of doctor’s rostered hours

Appointment shortages

Rooms not double-booked

For more information please refer to policies:

Practice services, Chapter 1.2 - Triage Practice services, Chapter 3 - Home and other visits Practice services, Chapter 4 - Care outside normal opening hours

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 1


1.1.1. Booking an appointment

1. Ask the patient which doctor they would like to see.

2. Ask the patient to provide a name if not given.

3. If the patient is new, inform of practice location, parking, costs and payment methods (if applicable). Obtain phone number and other demographics as required.

4. Ask if the appointment is urgent.

5. Ask if the consultation will require a longer appointment (>15 minutes). For new patients, allow 30 minutes for the appointment.

6. Provide the nearest available appointment time for the patient to see their preferred doctor.

7. If the patients preferred doctor is not available, ask if another doctor would be suitable or if non-urgent, if they are happy to select another time and date.

8. Provide the patient with a time and date for the appointment.

9. Record the patient surname and given name in the agreed timeslot.

10. Reconfirm the appointment time and date, and the patient’s phone number.

1.1.2. Rescheduling an appointment – changed by a patient

1. Ask the patient the time and date of the appointment, the doctor and type of appointment made.

2. Delete the cancelled appointment.

3. Ask the patient if they would like to reschedule the appointment for a different time and date.

4. Follow the procedures listed above in booking an appointment.

5. Record the patient name, date of appointment cancellation, the number of times that they have cancelled the appointment (eg Joe Bloggs; 23/10/2012 – 1) and the date the appointment has been rescheduled in Did Not Attend (DNA) system.

6. Provide the practice manager with the DNA system at the end of the day.

7. The practice manager will review the DNA system and triage them into A B C Categories based on urgency of need, follow up or action as appropriate and leave comments.

1.1.3. Rescheduling an appointment – changed by the practice

1. Contact the patient as soon as possible to let them know of the required change.

2. Mark these appointments specifically until changes are completed.

3. Offer the patient apologies and ask if they would like to reschedule the appointment for a different time and date.

4. Delete the cancelled appointment.

5. Follow the procedures listed above in booking an appointment.

6. If unable to contact patient, discuss with doctor as soon as possible.


2 Policy and Procedure Practice Manual I [Type the company name]


1.1.4. Recording missed appointmentsSelect the most appropriate option for your practice, or create your own procedure.

<Option 1>

Cancellations and missed appointments are monitored and recorded in the appointments diary.

Reception staff will mark in the appointments schedule that the patient did not attend (DNA).

Reception staff will provide each doctor with their appointment schedule at the end of the day.

The doctor will review their schedule, triage missed appointments and action as appropriate, taking into account patient history.

The doctor will advise the reception staff of which patients to contact and reschedule if necessary in accordance with triage procedures.

Reception staff will record in the appointments schedule whether or not another appointment has been made as well as any other comments.

Ensure that appointments flagged as recall appointments are rescheduled and remain on the recall monitoring list until the patient has attended a consultation with the doctor.

Patients who are called and have forgotten or have no adequate reason for not attending will be advised of the practice policy on cancelled and missed appointment fees.

<Option 2>

Cancellations and missed appointments are monitored and marked accordingly in the DNA system.

Reception staff will record DNA patient information in the DNA system, including:

Patient name; Date of appointment cancellation; The number of times that they have cancelled the appointment; and The date the appointment has been rescheduled.

Reception staff will provide each doctor with their appointment schedule at the end of the day.

The doctor will review their schedule, triage missed appointments and action as appropriate, taking into account patient history.

The doctor will advise the reception staff of which patients to contact and reschedule if necessary in accordance with triage procedures.

Reception staff will record in the appointments schedule whether or not another appointment has been made as well as any other comments.

Ensure that appointments flagged as recall appointments are rescheduled and remain on the recall monitoring list until the patient has attended a consultation with the doctor.

Patients who are called and have forgotten or have no adequate reason for not attending will be advised of the practice policy on cancelation and missed appointment fees.

For more information see:

Practice services, Chapter 1.1.5 - Cancelled and missed appointment fees Practice services, Chapter 1.2 - Triage




1.1.5. Cancelled and missed appointment feesOur patients are asked to provide at least insert time period notice to cancel an appointment.

Patients who repeatedly, define acceptable limit, do not attend scheduled appointments or cancel with less than insert time period notice will be advised that any further missed appointments without suitable notice will in future be charged a standard consultation fee as a deposit over the phone prior to making any further appointments. This fee will be deducted from the consultation fee charged for the service provided at attendance, or refunded if the patient is bulk billed.

The non-attendance fee is not refundable from Medicare.

Information about this policy is found on public display:

In the patient waiting room

At the reception counters

In the patient information brochure

Advised over the telephone and when making appointments with new patients


Practice services, Chapter 1.2 – Triage Practice services, Chapter 2.1.10 - Handling difficult patients




1.2. TriageThis practice classifies patients seeking medical consultations according to priority of need. Our triage system ensures that clinical care is provided to patients with urgent medical problems as a priority. At the beginning of their employment, staff are orientated to our triage system and given training to ensure it is used effectively. All staff are required to regularly update cardiopulmonary resuscitation (CPR) and other first aid skills.

The EMERGENCY ACTION PLAN and FRONT DESK TRIAGE POSTER are posted in the reception area to enhance accessibility.

It is the policy of this practice that patient’s calling who are suffering from the following symptoms be immediately transferred to a doctor:

Chest pain

Breathing difficulties

Sudden onset of a severe headache

Poisoning

To determine urgency (and to triage the patient), follow the FRONT DESK TRIAGE POSTER steps and ask the following questions:

Do you have an urgent problem?

If the answer is no, offer the next available appointment. If the answer is yes, continue.

Collect patient details including:

The patient’s phone number What is the name and age of the patient? What is the nature of the problem? What is the duration of the problem? What is the severity of the problem? Has the patient had any previous major health problems?

Select a priority category based on symptoms.

Follow the instructions for actions.

Consider the following flags during the conversation for attention:

Level of distress or anxiety

Terms used such as ‘severe’

The elderly >65 years and the very young < 3 years

Check the triage poster for symptoms

For more information see: Safety, quality improvement and education 7.2 - First aid and cardiopulmonary

resuscitation skills

Triage guide for general practice. Hunter Urban Division of General Practice. www.triageguide.com.au



http://www.triageguide.com.au/


1.1. Emergency telephone call with doctor presentUnder no circumstances are non-clinical staff to give medical advice.

Category 1 Call the doctor or nurse for help immediately. Advise the patient to call 000 for immediate attention; or Keep them on the line and call 000 on their behalf, (by seeking assistance from another

staff member) if the location is known. Once the ambulance has been despatched, remain on the line until its arrival to care for the

patient. You may be asked to speak to the ambulance officers attending the scene. Once you have been given the OK to hang up, retrieve the patient file. Document the

activity.

Category 2 Direct the patient to go to the nearest emergency department immediately, or if unable, call

000. Interrupt the doctor or nurse for help immediately. Retrieve the patient file for the doctor or nurse. Document the activity.

Category 3 Put the call through to the doctor or nurse as soon as possible. The doctor or nurse will make the clinical decision to tell the patient to come to the surgery

or direct them to 000 for an ambulance to transport the patient to the emergency department.

Retrieve the patient file for the doctor or nurse. Document the activity.

Category 4 Advise the patient or caller to come to the surgery now. Let the doctor or nurse know of the patient’s condition, action taken and when they are

expected to arrive. Retrieve the patient file for the doctor or nurse. Document the activity.

Category 5 Make an appointment for today and advise the patient to call back if symptoms worsen. Let the doctor or nurse know of the patient’s condition, action taken and when they are

expected to arrive. Retrieve the patient file for the doctor or nurse. Document the activity.

Category 6 Make an appointment within 24 hours and advise the patient to call back if symptoms

worsen. Inform nurse or doctor. Retrieve the patient file for the doctor or nurse. Document the activity.




1.2. Emergency telephone call and no doctor presentCategory 1 or 2

If a Category 1 or 2, call an ambulance on behalf of the patient and give the ambulance the patient’s location, telephone number and an indication of their condition.

Call the hospital that they will be attending and provide details of the patient coming in and an indication of their condition.

Contact the doctor and advise him or her of the emergency and the action that you have taken.

Category 3

If a Category 3, advise the patient to go to the nearest emergency department.

Call the emergency department that they will be attending and provide details of the patient coming in and an indication of their condition.

Contact the doctor and advise him or her of the emergency and the action that you have taken.

1.3. Emergency patient presents to reception with doctor presentCategory 1 or 2

If Category 1 or 2, attend to the patient following the DRABC (Danger Response Airway Breathing Circulation) Action Plan and ask another staff member or bystander to call the doctor and call an ambulance on ‘000’.

Refer to EMERGENCY ACTION PLAN for further information. Assist the doctor as required.

Category 3

If a Category 3, assist the patient to the treatment or consulting room and make them comfortable.

Call or ask another staff member to inform the doctor of the patient’s arrival and an indication of their condition.

Assist the doctor as required.




1.4. Emergency patient presents to reception and no doctor presentCategory 1 or 2

1. If a Category 1 or 2, implement the DRABC (Danger Response Airway Breathing Circulation) Action Plan, conduct a primary examination and if necessary stabilise him or her. Please refer to EMERGENCY ACTION PLAN for further information.

2. Ask another staff member or bystander to call an ambulance on ‘000’. If available, contact on-call doctors, the practice nurse or other practice staff for assistance.

3. Thoroughly review the patient by conducting head-to-toe secondary examination. Pay attention to the history (what happened to the patient), symptoms (indication of pain from the patient) and signs (what you can see for yourself).

4. If the patient is conscious, treat the injuries or illness according to the symptoms and signs.

5. If the patient is breathing sporadically, leave in a lateral position and treat any injuries.

6. If the patient has a pulse but is not breathing, commence mouth to mouth (Expired Air Resuscitation – EAR).

7. If the patient does not have a pulse but is breathing, commence cardiac compression.

8. If the patient does not have a pulse and is not breathing, place the patient on their back and commence mouth to mouth and cardiac compression (Cardio Pulmonary Resuscitation – CPR).

9. Stay with the patient until definitive care (ambulance) arrives.

10. When the ambulance arrives, call the hospital that they will be attending and provide details of the patient coming in and an indication of their condition.

11. Contact the doctor and advise him or her of the emergency and the action that you have taken.

Category 3

If a Category 3, assist the patient to the treatment or consulting room and make him or her comfortable.

1. Ask another staff member or bystander to call an ambulance on ‘000’. If available, contact the on-call doctor.

2. Stay with the patient until definitive care (ambulance) arrives.

3. Call the emergency department that they will be attending and provide details of the patient coming in and an indication of their condition.

4. Contact the doctor and advise him or her of the emergency and the action that you have taken.




1.5. Patient discomfort in waiting roomPatients in distress are to be regarded as urgent medical matters whether the contact is in person or by phone. Occasionally patients will arrive in the waiting room in a state of physical or emotional distress. Such patients may present as tearful, bleeding, aggressive, in pain or in a comatose/unconscious state.

1. Refer to triage procedures to correctly handle such a situation.

2. Notify the doctor immediately. Be prepared to call an ambulance if requested.

3. Provide an alternative area for the patient to wait, for example, treatment room.

4. Remain with the patient and reassure them while they are waiting.

5. Avoid touching a patient who is being difficult to deal with or aggressive.

1.6. Dialling emergency ‘000’In the event of an emergency, dial 000 (free call) and ask for “ambulance”.

You will then be transferred to the St John Ambulance Australia State Operations Centre (WA).

Advise the operator that you are calling from a general practice.

The operator will ask you some important questions, including:

The address of where the ambulance is required What the problem is How many people are injured/unwell The patient's age The patient's gender If the patient is conscious If the patient is breathing

The operator may provide you with ambulance pre-arrival advice to assist the patient.

It is important that you DO NOT HANG UP until the operator tells you to. You may have to hold the line while an ambulance is dispatched.

For more information, see:

Practice services, Chapter 1.2 - Triage




1.7. Subsequent action following an emergency or exceptional situationIt is important that, following an emergency or exceptional situation within the practice actions, processes and outcomes are reviewed to ensure that the situation has been handled effectively and identify whether or not any improvements can be made.

Following an emergency or exceptional situation:

Comprehensive notes must be detailed in the patient’s record, even if the patient has not presented to the practice before.

It is recommended that the doctor contact their medical defence organisation to make sure that they have handled the emergency correctly.

It is recommended that debriefing in a formal setting occur with all staff to discuss how the situation was handled, whether or not it could have been handled differently, whether the current policy and procedures are adequate and may require alteration.

1.8. Referring important information to the general practitionerOur reception staff are trained to take telephone calls and identify under which circumstances calls should be transferred to a medical practitioner or practice nurse.

The general practitioners will make time at the end of each session to attend to messages, return telephone calls or take calls from patients or other health professionals.

All contact of a clinical nature will be recorded in the patient health record.

If the reception staff receive a call from the pathology laboratory, radiology department, hospital or other health service identifying that they are returning the doctor’s call or are calling about a patient:

Ask if the call is urgent, or if the caller is returning the doctor’s initial call.

If identified as urgent, or if the doctor has the patient with them at the time, the caller should be placed on hold and the doctor interrupted.

Identify the caller and the patient concerned to the doctor, and transfer the call to the doctor.

If the doctor is not available (in the treatment room or not present) and the caller maintains urgency, the call should be put through to the nurse.

If there is no doctor or nurse on duty, and the caller maintains urgency, take down the patient details and telephone number of the caller and telephone the:

a. Referring general practitioner; or b. Rostered on-call general practitioner.

Provide the general practitioner with the patient details and telephone number of the caller and ask the general practitioner to telephone the caller back.

Please refer to:

FRONT DESK TRIAGE POSTER




1.9. Length of consultationsEach doctor has specific times allocated to his/her consulting sessions with documented needs for interval times, short and long consultations, diagnostic tests and procedures.

There will not be more than six (6) appointments made for any one (1) hour period and. unless in specific circumstances as expressed by the doctor, there will not be any appointments scheduled for less than ten (10) minutes.

Our standard appointment time is <standard appointment time>.

One (1) appointment is required for each family member requesting to be seen.

Should a longer consultation be requested or determined by information received from the patient, then our staff will endeavour to allocate the appropriate time. Our PRACTICE INFORMATION SHEET, states that patients can readily request a longer time when making an appointment.

If a patient requires a long consultation (eg requesting the completion of a doctor’s report) and they have not booked one, unless in exceptional circumstances, the doctor reserves the right to advise the patient that they will need to schedule another visit specifically for that need. This decision is made on a discretional basis.

1.10. Patients with special needsOur general practitioners and staff are aware of alternative modes of communication for our patients with special needs.

Posters and pamphlets to this effect will be made available in the patient waiting room encouraging patients and carers to make longer appointments if there are complex medical needs, communication difficulties or impaired cognition. Posters will also advise of the availability of translator services if necessary.

Where communication is difficult, patients with special needs will be offered assistance from one of the following (or other services such as family member as identified):

National Relay Service for patients who are deaf

Translation and Interpreter Service for patients from a non-English speaking background

For more information see policies on:

Our practice, Chapter 3 - Practice contacts Practice services, Chapter 7 - Interpreter and other communication services




1.11. Practice closuresShould our practice be required to close outside of our normal opening hours, such as during the holiday season or on a long weekend, the practice manager will post a notice on the front door and in the waiting room no less than four (4) weeks prior to the closure to advise patients of alternative arrangements.

Alternative arrangements may include:

Directing patients to a nearby after hours medical centre

Directing patients to an alternative general practice

Directing patients to the nearest accident and emergency department

For more information see policies on:

Our practice, Chapter 2.3 - Opening hours Practice services, Chapter 3 - Home and other visits Practice services, Chapter 13 - Clinical handover

1.12. VisitorsPatients and other visitors are warmly welcomed to the practice. Doctors and staff value the principles of good relationships whether they are maintained in person, via written or electronic communication or on the telephone. Visitors including patients, relatives, friends, health care providers, students, pharmaceutical/medical supplier representatives and Medicare Local representatives are shown friendly, courteous recognition and assistance.

When a person presents at reception or lingers in the main entrance or other areas of the practice and remains unidentified, ask if you may help and elicit the reason for their presence on the site.

Ask the person to wait in the waiting room.

If the visitor looks suspicious, call a doctor or other staff member to assist.

If the person is booked to see a doctor or staff member, check with them and their appointment diary to ensure the visitor can be seen at that time.

If the visitor is an unsolicited representative with no appointment pre-arranged, request the visitor to come back at another pre-booked time.




2. TELEPHONE AND OTHER COMMUNICATIONS (CRITERION 1.1.2)

Policy

Patients of our practice are able to obtain timely advice or information related to their clinical care by telephone and electronic means (where in use) where a general practitioner determines that this is clinically safe and that a face-to-face consultation is unnecessary for that patient.

1.13. Telephone communicationOur practice patients are able to obtain information or advice related to their clinical care by telephone in a situation where a consultation is unnecessary or impractical.

The following are guidelines for phone calls to the practice. These are guidelines only and if you are in any doubt you must check with the treating or duty doctor.

In all cases of requests for personal information such as request for results by phone, our practice staff will use a minimum of three (3) patient identifiers so that patient confidentiality is not compromised.

The RACGP recommended patient identifiers are:

Patient name (family and given names)

Date of birth

Gender (as identified by the patient themselves)

Address

Patient record number where it exists

Select the most appropriate option for your practice, or create your own procedure.

<Option 1>

The doctors in this practice do not take any calls while they have a patient with them unless it is a medical emergency. All other calls will be returned as soon as possible.

<Option 2>

The doctors in this practice will only take calls in a medical emergency or calls regarding a patient from other medical practitioners, the pharmacy, radiology or pathology providers. All other calls will be returned as soon as possible.

<Option 3>

The doctors in this practice prefer that all calls be put through to them unless they are performing a procedure.

<Option 4>

The doctors in this practice will accept calls if they are between consultations, unless it is a medical emergency. Otherwise all calls will be returned as soon as possible.




For more information please see policies on: Practice services, Chapter 1.5 - Patients with special needs Practice services, Chapter 7 - Interpreter and other communication services

1.1.1. Telephone techniques1. Always answer the phone regardless of your location in the practice. It is important that you

either divert the phone through to where you are or ask the person on phone backup to take the calls.

2. Speak with a respectful and calm tone. This also applies in face-to-face conversations.

3. Smile when you dial out or answer the phone. Smile when talking on the phone as this comes through in your voice.

4. Have a pen and notebook ready.

5. Wait a moment before talking. Don’t rush the caller.

6. Feel comfortable confirming details with the caller including how they spell their name.

7. Focus on the call you are taking.




1.1.6. Answering incoming calls1. Answer the telephone within three (3) rings.

2. Greet all external callers with:

Good morning/afternoon, <name of practice> This is (insert your name). How can I help you?

3. Ask if the patient is new or has attended the practice before.

4. If the patient is calling to request an appointment, ask the patient which doctor they would like to see.

5. Ask if the appointment is urgent (follow FRONT DESK TRIAGE POSTER steps).

6. Provide the nearest available time for the patient to see their preferred doctor.

7. If the patient’s preferred doctor is not available, ask if another doctor would be suitable or if non-urgent, if they are happy to select another time and date.

8. Ask if the consultation will require a longer appointment (>15 minutes).

9. For new patients, allow a longer consultation (approximately 30 minutes) for the appointment.

10. Provide the patient with a time and date for the appointment.

11. Ask the patient to provide the minimum demographics to confirm identity and enter the patient (if new) into the practice software:

Surname, first name Date of birth Address Telephone number

12. Ask if the patient holds any Commonwealth Concession Cards.

13. Explain the practice policy on payment, fees and payment methods (if applicable).

14. Explain the practice location, parking, costs and reconfirm the appointment time and date.

1.1.7. Placing callers on hold1. Our practice ‘on hold’ message provides advice to call 000 in case of an emergency.

2. Always ask the caller’s preference before placing them on hold, and always wait for the caller to respond.

3. If you are on another call and the phone is ringing, ask the caller if you can place them on hold for a moment. If the caller agrees, place them on hold and answer the next call. Ask this second caller if they can hold a moment. If they agree, return to your other call.

4. If you have a caller on hold for more than a minute, ask if they are still happy to continue holding or if they would like to leave a message. Repeat this process every 60 seconds.

5. Ensure practice on-hold music or message is working and can be clearly heard.




1.1.8. New patientsNew patients will be advised of the following information during the initial phone enquiry or booking of an appointment.

Fees charged

Appointment time

Appointment length

Type of appointment

Doctor’s name

The following information is to be provided to a new patient during the first visit.

Patient information sheet

Services and special interests

Reminder system availability

After hours care arrangements

Fee structure

Billing and payment system

Practice hours

Availability of home visits

1.1.9. Telephone requests for referralsSelect the most appropriate option for your practice or create your own procedure.

<Option 1>

Patients at times will telephone or call in and ask for a referral letter/repeat referral letter to a specialist. It is the policy of this practice that all patients are provided with a free referral letter.

<Option 2>

Patients at times will telephone or call in and ask for a referral letter/repeat referral letter to a specialist. All patients are required to make an appointment with a doctor for referral letters. There are no exceptions.

<Option 3>

Patients at times will telephone or call in and ask for a referral letter to a specialist. All patients are required to make an appointment with a doctor for a referral letter. This excludes patients who require an ongoing referral letter. Such exclusion is based on the discretion of the treating doctor.




1.1.10. Telephone requests for repeat prescriptionsFor regular medications, patients are encouraged to ensure that they have a sufficient number of repeat prescriptions before leaving the surgery, to ensure continuity of medication until their next scheduled visit.

Select the most appropriate option for your practice or create your own procedure.

<Option 1>

Patients at times will telephone or call in and ask for repeat prescriptions. It is the policy of this practice that patients are provided with a repeat prescription without a doctor’s consultation on request. This will be at the doctor’s discretion. In this circumstance a fee of <fee to access a repeat prescription> will be charged and is payable at the time of collecting the prescription.

<Option 2>

Patients at times will telephone or call in and ask for repeat prescriptions. It is the policy of this practice that all patients are required to make an appointment with a doctor for repeat prescriptions. There are no exceptions.

<Option 3>

Patients at times will telephone or call in and ask for repeat prescriptions. It is the policy of this practice that patients who have attended the practice within the previous <period since patient last visited their doctor> are provided with repeat prescription at a cost of <fee>.

Patients who have not attended the practice within the <period since patient last visited their doctor> period must schedule an appointment to see the doctor.

In all cases, the doctor will not provide a repeat prescription for antibiotics, sedatives, analgesics and authority medications without a consultation.




1.1.11. Telephone requests for resultsPatients at times may telephone and ask administrative staff for test results. It is very important that patients and staff understand the policies of this practice. Due to the serious nature of many of these tests it is vital that all staff adhere to the following policy. During an appointment, the doctor will explain this practice’s policy to all patients to reinforce its importance. Information about our practice policy on obtaining results is also included in our practice information sheet.


<Option 1>

No results are given out over the phone by administrative staff. There are no exceptions to this rule. All requests are given to the practice nurse as the initial point of contact and, should the nurse feel necessary, then to the appropriate doctor as for other telephone messages.

Advise the patient that it is the policy of this practice that no results are given out over the phone by administrative staff and that there are no exceptions to this.

Advise the patient that you will take a message and ask the doctor to return their call as soon as convenient.

<Option 2>

No results are given out over the phone by any staff member. There are no exceptions to this. All patients are required to make an appointment to see their doctor to discuss their results.

Advise the patient that it is the policy of this practice that no results are given out over the phone by any administrative staff member and that there are no exceptions to this.

Advise the patient that all patients are required to make an appointment to see their doctor to discuss their results.

Offer the patient the opportunity to make an appointment.

<Option 3>

Results may be given over the phone by administrative staff only on the written request from the doctor. If for any reason the staff member is not comfortable giving the results they must inform the doctor concerned. The staff member must ensure that they check the identity of the caller by requesting the caller’s full name and date of birth. Only the person whose name appears on the results may be given the information, unless the patient is a child.

Check the identity of the patient by no less than three patient identifiers:

Patient name (family and given name) Date of birth Gender (as identified by the patient themselves) Address Patient record number where it exists

Provide the patient with the exact information as requested by the doctor.

Offer the patient the opportunity to make an appointment if they wish to discuss the results.




If there is any doubt (for example a pregnancy test for a 13-year-old), then no results are to be given and the caller must be referred to the doctor. It is very important that administrative staff only pass on the information as requested by the doctor. For example “The doctor has asked me to tell you that your pap smear result is normal”. Administrative staff must never be drawn into interpretation or discussions on the meaning of test results. If patients wish to discuss their results, they must make an appointment to see their doctor.

1.1.12. Taking messagesAll staff will remain up-to-date with each doctor’s policy with regards to returning patient phone calls.

It is the responsibility of all medical and non-medical staff to check for his or her messages. Staff will only verbally pass on urgent and important messages.

Patient messages taken for subsequent follow up by a doctor or staff member will be documented for their attention and actioned as appropriate.


<Option 1>

This practice uses a telephone message pad to relay the message. A carbon copy of the message is kept at reception.

<Option 2>

This practice uses internal email to relay telephone messages to the doctor.

<Option 3>

<practice own policy>




1.1.13. Clinical messagesIf a message from a patient is of a clinical nature, the patient is to be offered the practice nurse in lieu of the general practitioner. If an email message is sent to the general practitioner, the practice nurse will be copied in for follow up.

When taking a message, record the following details in the message:

Date

Time of the call

Full name of caller and of patient if different

Telephone number

Reason for the call

Action to be taken

Name of staff member taking message

Repeat the details back to the caller to ensure that they have been noted correctly

Deliver the message as detailed above on the day of receipt, or in that person’s absence, to the person who is caring for that absent team member’s patients

Please refer to:

FRONT DESK TRIAGE POSTER




1.1.14. Outgoing callsTo ensure that incoming calls are not interrupted, this practice prefers that all outgoing calls are made on <outgoing call line numbers>.

Our most commonly used and emergency telephone numbers have been programmed into the speed dial. Brief personal calls can be made only if necessary and when they do not interfere with work.

The home and mobile telephone numbers of practice staff are private and are not to be given to anyone without the express permission of the practice principal or practice manager.

For more information please see policies on:

Our practice, Chapter 3 - Practice contacts

When making calls on behalf of the practice such as to a hospital or specialist rooms:

Identify yourself by name and practice

Identify why you are calling and whom you wish to speak to

If patient details are to be discussed, such as following up on results, identify the patient in no less than three patient identifiers

Patient name (family and given name) Date of birth Gender (as identified by the patient themselves) Address Patient record number where it exists

If a message is to be left, repeat the details back to the operator to ensure they have been noted correctly

When making a call to a patient at home, the procedure must maintain the privacy and confidentiality of the patient.

Do not identify where you are calling from. Maintain a pleasant manner.

Ask for the patient by name.

If the patient is not available do not leave a return number or message.




1.1.15. Handling difficult patientsAt times a doctor may not be able to effectively treat their patient due to lack of rapport or because the patient frequently challenges decisions or recommendations given. In these cases, it is recommended that the doctor does not persevere with the patient but finds another doctor that would better suit the patient’s personality. This is to ensure appropriate care is provided to the patient but to also prevent potential litigation.

1. Advise the patient that you do not feel that you will be able to effectively treat them because of ______________________ <insert reason>.Ensure that you take ownership of the reason why you feel that you cannot adequately treat the patient.

2. Advise the patient that you have a sincere desire that they receive the appropriate care and that they may receive this by another doctor who better understands their needs.

3. Ask the patient if they have another doctor in mind that they would like to attend.

4. If no, recommend to the patient a doctor who you consider would be better able to care for them.

5. If the patient agrees, ask the patient if they would like you to make an appointment for them.

6. If yes, make the appointment during the consultation and provide the patient with the appointment time and with the new doctor’s contact and address details.

7. Make a note in the patient’s medical record of the action taken and the appointment date. Also record a reminder in the patient’s medical record to call them after the appointment.

8. After the scheduled appointment, contact the patient to ensure that they are satisfied with their new doctor.

9. Further to Step 3, if the patient indicates that they would like to continue in your care, advise them that there will need to be some ‘ground rules’. For example, if the patient frequently challenges your opinion, advise the patient that all recommendations you make are in their best interest and, if they would like you to continue treating them, they are to accept them.




1.14. Electronic communicationThis practice may use electronic means (email and SMS) to communicate with a patient or carer. At all times, the clinical team will consider the quality and safety of care when providing information by telephone or electronic means. Staff will be mindful of personal information privacy and only use electronic means of communication in the following circumstances:

where the patient or legal guardian has completed the NEW PATIENT QUESTIONNAIRE which includes permission to use electronic means of communication

in non-urgent conditions only

to remind the patient of an upcoming appointment

to send a non-urgent reminder or recall for follow up or regular testing

A record of the communication will be kept in the patient records. If a fee is to be charged for the telephone or electronic communication, patients will be made aware of this and information about the costs will be made readily available.

1.15. Telephone and electronic equipmentThe practice needs sufficient telephone and electronic equipment to support reliable and efficient communications. An incoming telephone call is the principle method for initial and subsequent communication with a patient and most other persons to this practice.

As such the telephone is recognised as a vital medium for creating a positive first impression, displaying a caring, confident attitude and acting as a reassuring resource for our patients and all others.

All staff will be trained to use the telephone system and other electronic means of communication using the following procedures.

1.1.16. Telephone functionsAll staff will be taught to use the following phone functions:

Put on hold

Retrieving calls from on hold

Answer other calls

Transfer calls

Using the intercom

Answering from other extensions

Program the after-hours message

Program on-hold music or message

Divert to after-hours service provider

Activate/deactivate answering machine

The operations manual for this telephone system is located at <telephone operation manual location> .




1.1.17. Telephone problemsThe following incidents must be reported to the practice manager if they cannot be fixed quickly by staff:

Telephones do not work due to power failure.

Loss of music/on-hold message and staff are unable to reprogram.

Loss of recorded messages and staff are unable to reprogram message.

For equipment failure, contact the telephone equipment provider listed in:

Our practice, Chapter 3.1 - Business and service provider contacts

For landline failure, contact the communications provider listed in:

Our practice, Chapter 3.16 - Emergency contacts

1.1.18. EmailPatient information is only sent via email if it is securely encrypted according to industry and best practice standards.

This practice may use electronic means (email and SMS) to communicate with a patient or carer. At all times, the clinical team will consider the quality and safety of care when providing information by telephone or electronic means. Staff will be mindful of personal information privacy and only use electronic means of communication in the following circumstances:

where the patient or legal guardian has completed the permission to use electronic means of communication;

in non-urgent conditions only;

to remind the patient of an upcoming appointment; or

to send a non-urgent reminder or recall for follow up or regular testing.

A record of the communication will be kept in the patient records. If a fee is to be charged for the telephone or electronic communication, patients will be made aware of this and information about the costs will be made readily available.

1.16. Fees for telephone and electronic communicationsOur practice may/will not conduct telephone consultations when the patient cannot attend the surgery.

Patients will be advised in advance of the fee and that any billing for this style of consultation is not claimable through Medicare and a private invoice will be raised.


Our practice, Chapter 4 - Practice consultation fees




3. HOME AND OTHER VISITS (CRITERION 1.1.3)

Policy

Regular patients of this practice are able to obtain visits in their home, residential aged care facility, residential care facility or hospital, both within and outside normal opening hours where such visits are deemed safe and reasonable and where the patient is:

Acutely ill

Immobile or elderly

Has no means of transport to the practice

If disabled access to the practice is unsuitable

Our doctors, and where appropriate, practice nurses or Aboriginal health workers, have home visit schedules, which are recorded in the appointment book at reception.

1.3. Providing safe and reasonable careOur practice ensures safe and reasonable arrangements are in place for medical care for patients outside our normal opening hours.

Prior to making a home visit, the following steps must be considered: Visits are made to patients located within a 15 kilometre radius of the practice

Patients must have a telephone number which the general practice can call back

A health professional is not sent to a patient/caller requesting pain relief unless a pain management plan is in place

Police are requested to attend when a patient is threatening suicide

A health professional is not sent to a premises where there is evidence of a threatening or abusive person present – police are requested to attend in these instances

Callers are asked to restrain dogs, to turn on an outside light at night and provide guidance on identifying the residence in the absence of a house number (eg nearest intersection, landmark)

Patients are asked to provide their date of birth, and the name of their regular general practice. Where these details are not given or the patient is not known to the practice, consideration is given to referring the patient to a hospital or calling an ambulance (as appropriate)

1.4. Access to alternative sources of careIf our practice team decides that there is cause for concern or the option of a home or other visit is not safe or reasonable for the staff member or the patient, the patient will be referred to an alternative mode of care.

This decision and the known outcomes will be recorded in the patient health record.




1.17. Who can perform home or other visitsOur clinical staff, including doctors, nurses and Aboriginal health workers are appropriately trained and qualified to meet the needs of our practice community.


<Option 1>

Only general practitioners will provide home or other visits, providing the arrangements are deemed safe and reasonable.

<Option 2>

Our medical practitioners will provide home or other visits, providing the arrangements are deemed safe and reasonable.

Practice nurses and Aboriginal health workers may provide home and other visits under the supervision and instruction of the medical practitioner, providing the arrangements are deemed safe and reasonable.

<Option 3>

Our practice has a formal arrangement and written agreement with <name of home visit provider> to provide home and other visits to our patients.

Information about our home visit policy is available in the patient information sheet and on the front door of our practice.


Practice services, Chapter 4 - Care outside normal opening hours Safety, quality improvement and education, Chapter 5 - Qualifications of general

practitioners




1.18. Safety of health professionalsThis practice has a policy of promoting staff security by having appropriate procedures in place that will minimise risk to staff.

Our practice recognises the RACGP Standards for General Practices: Fourth edition guidelines for the safety of health professionals undertaking home and other visits (as adapted from the National Association for Medical Deputising Services):

Patients must have a telephone number which the general practice can call back.

A health professional is not sent to a patient/caller requesting pain relief unless a pain management plan is in place.

Police are requested to attend where a patient is threatening suicide.

A health professional is not sent to premises where there is evidence of a threatening or abusive person present – police are requested to attend in these instances.

Callers are asked to restrain dogs, to turn on an outside light at night and provide guidance on identifying the residence in the absence of a house number (eg nearest intersection).

Patients are asked to provide their date of birth, and the name of their regular general practitioner/general practice. Where these details or a contact telephone number are not provided, consideration is given to referring the patient to hospital or calling an ambulance (as appropriate).




4. CARE OUTSIDE NORMAL OPENING HOURS (CRITERION 1.1.4)

Policy

Our practice ensures safe and reasonable arrangements for medical care for patients outside our normal opening hours.

1.5. Options for care outside normal opening hoursSelect the most appropriate option for your practice or create your own procedure.

<Option 1>

Our doctors provide their own care for patients outside normal opening hours, either individually or through a roster. Information about this service is made available on our front door notice and on our on-hold/after-hours message.

<Option 2>

Formal arrangements for cooperative care outside the normal opening hours of our practice exist through a cooperative of one or more local practices. Information about this service is made available on our front door notice and on our on-hold/ after-hours message.

<Option 3>

Formal arrangements with an after-hours deputising (locum) service, name <service name> is available for after-hours care. The contact number is <after-hours phone number>. The deputising service is able to make contact with the patient’s doctor if necessary to ensure measures are implemented to facilitate continuity of care. Information about this service is made available on our front door notice and on our on-hold/after-hours message.

<Option 4>

This practice provides after-hours care through a formal arrangement with the <name of after-hours care hospital>. Patients requiring attention are requested to attend the Accident and Emergency Department of the <name of after-hours care hospital> or telephone 000 for an ambulance. Information about this service is made available on our front door notice and on our on-hold/after-hours message.

For more information see the RACGP Fact Sheet After-Hours Care [2015] - http://www.racgp.org.au/download/Documents/Standards/Fact%20sheets/standards-after-hours-criterion-fact-sheet-july-2015.pdf



http://www.racgp.org.au/download/Documents/Standards/Fact%20sheets/standards-after-hours-criterion-fact-sheet-july-2015.pdf

http://www.racgp.org.au/download/Documents/Standards/Fact%20sheets/standards-after-hours-criterion-fact-sheet-july-2015.pdf


1.6. Formal after-hours agreements<Options 2, 3 or 4> above

Our practice engages the services of a [1] cooperative of one or more local practices/[2] after-hours deputising service/[3] <name of after-hours care hospital> to provide after-hours care of our regular patients. A formal agreement is in place and includes:

Reference to the timely reporting of the care provided back to the patient’s regular doctor.

Steps to be taken to follow up and review test results requested by the after-hours deputising service.

Details of how and when the patient’s regular doctor will receive information about any care or tests undertaken by the deputising service.

A defined means of access for the deputising service/practitioner to patient health information and the regular doctor in exceptional circumstances.

Assessment by the practice that the care outside normal opening hours will be provided by appropriately qualified health professionals.

Patients are to be advised by the deputising service on what is required for follow up and treatment by the patient’s regular doctor.

A copy of our signed formal after-hours agreement is available from the practice manager and is located <location of formal agreement>.

1.7. Follow up of tests taken during after-hours careOur practice has a formal agreement with [1] a cooperative of one or more local practices/[2] an after-hours deputising service/[3] <name of after-hours care hospital> to provide a comprehensive after-hours service to our patients.

When the [1] cooperative of one or more local practices/[2] after-hours deputising service/[3] <name of after-hours care hospital> sees a patient after hours, the patient will be asked who their regular general practitioner is.

The [1] cooperative of one or more local practices/[2] after-hours deputising service/[3] <name of after-hours care hospital> will be provided with emergency mobile numbers of our practice general practitioners and are able to make contact with the patient’s usual general practitioner if necessary to ensure measures are implemented to facilitate continuity of care.

Where there are seriously abnormal or life threatening results the consulting doctor at the [1] cooperative of one or more local practices/[2] after-hours deputising service/[3] <name of after-hours care hospital> will follow up the results and report back to the patient’s usual general practitioner.

Copies of all diagnostic imaging and pathology reports will be sent to the regular general practitioner upon receipt by ordering doctor or upon discharge by the hospital.

Information about this service is made available on our front door notice and on our on hold/after-hours message.




1.8. Who can provide after-hours care for the practiceOur clinical staff, including doctors, nurses and Aboriginal health workers are appropriately trained and qualified to meet the needs of our practice community.

Information about our home visit policy is available in the patient information sheet and on the front door of our practice.


Practice services, Chapter 4 - Care outside normal opening hours Safety, quality improvement and education, Chapter 5 - Qualifications of general

practitioners

1.9. Communicating our after-hours arrangements Select the most appropriate option for your practice, or create your own procedure

<Option 1>

This practice has an after-hours phone message which states <content of after-hours message>. It is the responsibility of the <member responsible for maintaining after-hours phone message> to ensure that the after-hours message is working effectively and updated as necessary.

Details of our practice arrangements for after-hours care and emergency services are detailed on the front doors of our practice.

<Option 2>

This practice diverts the phone to our after-hours care provider when the practice is closed so that patients have access to care 24-hours a day, 7 days a week via our main telephone number.

Details of our practice arrangements for after-hours care and emergency services are detailed on the front doors of our practice.




5. PRACTICE INFORMATION (CRITERION 1.2.1)

Policy

Our practice provides patients with adequate information about our practice to facilitate access to care.

1.10. Practice information sheetOur practice information sheet is available to patients, accurate and contains at a minimum:

Our practice address and telephone numbers

Our consulting hours and arrangements for care outside our practice’s normal opening hours, including a contact telephone number

Our practice’s billing principles

Our practice’s communication policy, including receiving and returning telephone calls and electronic communication

Our practice’s policy for the management of patient health information (or its principles and how full details can be obtained from the practice)

The process for the follow up of results

How to provide feedback or make a complaint to the practice including contact details of the local state or territory health complaints conciliation body

It is the responsibility of <person responsible for updating patient information sheet> to ensure that the practice information sheet is kept up-to-date and copies are available at reception


PRACTICE INFORMATION SHEET

1.11. Advertising practice informationAll advertising carried out by our practice will comply with the Medical Board of Australia Code of Conduct and will include:

Factual and verifiable information about our practice and services offered

Justifiable claims about the quality and outcomes of our services

No guarantee of cures or exploitation of patients’ fears, or vulnerability about future health expectations

No inducements or testimonials

No unfair or inaccurate comparisons to competitor services




1.12. Practice websiteSelect the most appropriate option for your practice or create your own procedure.

<Option 1>

Our practice website contains up-to-date information about our practice services including:

Clinical and management staff

Schedule of common fees

Hours of operation

Contact details

After-hours arrangements

How to provide feedback

The practice manager is responsible for updating the website on a regular basis and where there are changes in the above details.

At a minimum the website will contain the same information as our PRACTICE INFORMATION SHEET.

<Option 2>

Our practice does not have a website.

1.13. Practice servicesIn addition to medical consultations, this practice offers the following services:

1.14. Practice hoursMonday to Friday

Weekends

Home Visits Home visit appointments can be made outside these times by prior arrangement with the doctor.


Practice services, Chapter 3 - Home and other visits Practice services, Chapter 4 - Care outside normal opening hours




6. INFORMED PATIENT DECISIONS (CRITERION 1.2.2)

Policy

Our practice gives patients sufficient information about the purpose, importance, benefits, risks and possible costs associated with proposed investigations, referrals or treatments, to enable patients to make informed decisions about their health.

1.15. Providing appropriate and sufficient information to patientsOur patients will be given comprehensive information to enable them to make informed decisions about their health care.

The information will include for all investigations, medications, treatment or surgery:

Purpose

Importance

Benefits

Risks

Possible costs

Referrals

When providing this information our medical practitioners will avoid the use of jargon or complicated medical terms and if possible provide diagrams or written information such as brochures or leaflets from our practice software for the patient to review (possibly with family or carers).

1.16. Informing patients of potential treatment costsComplaints may arise when patients receive accounts that are of an unexpectedly high cost.

It is the policy of this practice that doctors and staff are open and honest with patients in all discussions regarding costs. This does not necessarily mean that exact costs are provided to patients; however the patient must be made aware that there is potential for cost and an approximate indication of how much it will be.

This practice clearly outlines billing practices to patients through signage, the patient information sheet and verbally.




1.17. Patient-doctor collaborationOur medical practitioners value the patient doctor relationship and will acknowledge the rights of patients to question or discuss the provider’s referrals or treatments and to make decisions about their own healthcare.

Our medical practitioners may refer our patients to read a copy of the former Australian Council for Safety and Quality in Health Care publication, 10 tips for safer healthcare. A copy of the publication is available at

www.safetyandquality.gov.au/wp-content/uploads/2003/01/Tips-for-Safer-Health-Care-PDF-302KB.pdf



http://www.safetyandquality.gov.au/wp-content/uploads/2003/01/Tips-for-Safer-Health-Care-PDF-302KB.pdf



7. INTERPRETER AND COMMUNICATION SERVICES (CRITERION 1.2.3)

Policy

Our practice provides for the communication needs of patients who are not proficient in the primary language of our clinical team and/or who have a communication impairment.

Patients who do not speak English or who are more proficient in another language, have the choice of utilising the Translating and Interpreting Service (TIS).

1.18. Patients of foreign background and ethnicity If the patient requires an interpreter, ask the patient if they would like the use of an interpreter

and offer translation services available in the practice.

If an existing patient, check the patient’s medical record to see if an interpreter has been used before.

If a new patient, record the patient’s preferred language and if they have requested an interpreter. If an interpreter is required, record what service they would prefer to use (eg family member, friend, staff member or TIS).

Ask what time the patient would prefer their appointment and whether or not they would prefer a male or female interpreter. Also ask how the patient prefers to be addressed and their preferred order of name (eg family name first, then generation name, given name last).

Record this information in the patient’s medical record.

Make a long appointment to accommodate interpreting time.

Ask the patient to repeat appointment details back to you to confirm they have understood.

If the TIS is the chosen option, contact them to book an interpreter. Advise the TIS operator of a nominated patient code for easy identification, patient name and language, preferred gender of interpreter, and appointment details.

Once confirmed, ask the patient to call if they are unable to attend the appointment. Alternatively, call the patient the day before to confirm the appointment.

The TIS is a free service available via telephone at the time of consultation, or if appropriate, the interpreter can be on site at the practice (48 hours advance notice is required).




1.1.19. Translating servicesThis practice encourages the use of the free Translating and Interpreting Service (TIS) – Doctors Priority Line (1300 131 450) as we consider it the right of all patients with limited English to be provided with a professional interpreter.

Other reasons for using a professional interpreter include:

Risk management

Effectiveness

Efficiency

Accuracy

Impartiality

Confidentiality

Professional conduct

Experience

Patients are advised of this service by:

Translating and interpreting services

Waiting room and doctor’s room signage

Brochures

Patient information sheet

Reception

Doctor




1.1.20. Using friends and relatives as interpretersSelect the most appropriate option for your practice or create your own procedure.

<Option 1>

Patients may arrive with a family member or friend who could translate. Our practice discourages this (except in emergency situations) as it may present the following problems:

Reluctance for the patient to disclose some information

Biased translation of information

Misunderstood messages between the staff member and the patient

This practice also provides patient support materials in a variety of languages including <other languages support material provided>. The <position responsible for maintaining health and community services information> is responsible for the maintenance of these materials.

<Option 2>

It is the policy of this practice that staff members are not to be used as interpreters, except in emergency situations. This is because bilingual staff, unless appropriately accredited, should not be presumed to have the necessary skills to act as interpreters. If an unqualified interpreter has been used in an emergency, a qualified interpreter must be obtained as soon as possible to ensure the patient has understood what has taken place.

<Option 3>

The following staff members in this practice are fluent in these languages:

Name of staff member Language




8. COSTS ASSOCIATED WITH CARE (CRITERION 1.2.4)

Policy

Our practice informs patients about the potential for out-of pocket expenses for health care provided within our practice and for referred services.

1.19. Fees for services and billing practicesOur practice billing principles including a schedule of fees and services are displayed at the front desk, on our website, in the waiting room and in our PRACTICE INFORMATION SHEET. Staff will draw patients’ attention to the billing process whenever appropriate.

Where an increase to our private and third party fees will take place or a change in our billing principles, the practice will provide notices on our website, at the reception counter and in the patient information brochure for a period of no less than one month before the changes take effect.

It is the responsibility of the doctor to enter/advise reception staff of the appropriate Medicare item number(s) the patient is being charged for.

For more information on our schedule of fees, see:

Our practice, Chapter 4 - Practice consultation fees

1.1.21. Private billingSelect the most appropriate option for your practice or create your own procedure.

<Option 1>

All patients will be issued an invoice at the time of seeing the doctor. All invoices are payable on the day.

Problems regarding a patient’s ability to pay must be referred to the treating doctor. Unless in specified circumstances, patients will receive a bill from the doctor at the time of consultation.

Payments may be made by:

Cash

Credit card

EFTPOS

Direct deposit

Private cheques are not accepted

<Option 2>

All patients will be issued an invoice at the time of seeing the doctor.

Patients will be permitted to run an account.

However, payment at the time of consultation is encouraged whenever possible.




1.1.22. Bulk billingWhen bulk billing Medicare, it is the responsibility of reception staff to ensure that the practice has an up-to-date record of the patient’s Medicare card number and that all patients are offered a copy of their Medicare assignment form.


<Option 1>

This practice bulk bills all patients for Medicare Benefits Schedule (MBS) items where possible.

<Option 2>

This practice bulk bills Medicare for Medicare Benefits Schedule (MBS) items in the following circumstances:

At the discretion of the consulting doctor

For all Commonwealth Concession Card holders

All children under the age of 16

For follow up appointments; to receive results; for childhood immunisations

<Option 3>

This practice bulk bills Medicare for Medicare Benefits Schedule (MBS) items for:

Patients who are genuinely financially disadvantaged, regardless of social security status

All pensioners and health care card holders

Frail or aged patients and nursing home residents

People with chronic illnesses or those requiring frequent visits

Patients with an intellectual disability

Adolescents not accompanied by a parent or guardian

All children under the age of 16

Other doctors, health professionals and their families

Ministers of religion and their families

Families of practice staff




1.1.23. Department of Veterans’ Affairs The Department of Veterans’ Affairs (DVA) provides a range of benefits and services to veterans and their dependants for injury, disease or death which is related to service with the Australian Defence Force. Eligibility for benefits depends on where and when a veteran served.

This includes:

Current serving members

Former serving members

Carers

Families

DVA patients eligible for this service will hold a DVA card. These come in the following formats:

Gold card

A gold card entitles the holder to DVA funding for: All health care needs, for all health conditions, whether they are related to war service or not.

The card holder may be a veteran or the widow or dependant of a veteran; and

Only the person named on the card is covered.

Gold card holders may also be eligible for the Coordinated Veterans’ Care (CVC) program. The CVC targets gold cardholders who are more at risk of being admitted or readmitted to hospital.

White card for specific conditions only

The white card offers: Medical treatment of the accepted specific condition(s);

Transport related to treatment of the accepted specific condition(s); and

Access to Repatriation Pharmaceutical Benefits Scheme

The white card is issued to:

Eligible veterans for the care and treatment of accepted injuries or conditions that are war caused or service related;

For the treatment of malignant cancer, pulmonary tuberculosis, posttraumatic stress disorder, anxiety and/or depression whether war caused or not; and

Ex-service personnel who are eligible for treatment under agreements between the Australian Government and New Zealand, Canada, South Africa and the United Kingdom for disabilities accepted as war-caused by their country of origin.

Orange card for pharmaceuticals only

An orange card is issued to Commonwealth and allied veterans and mariners who:

Have qualifying service from World War I or World War II;

Are aged 70 or over; and

Have been resident in Australia for 10 years or more.




Treatment Authority letter

A Treatment Authority letter acts as ongoing approval from DVA for the client to access reasonable primary and allied health treatment as required (up to certain limits for some treatment types). This Treatment Authority states: The accepted condition/s that the client has.

All treatment outlined in the Treatment Authority letter is pre-approved.

Treatment Authority letters will be issued either at the point a needs assessment is undertaken, or when a client contacts DVA for medical approval.

Item numbers and fees for DVA are different from those for Medicare. If unsure, check with the practice manager.

1.1.24. Workers compensationWorkers Compensation is a form of insurance that is provided for all workers in the event of their being injured at work. A number of patients will present to the practice with a history that they have been injured in this way.

The patient is to lodge a claim with their employer, who must lodge relevant documentation with their insurance company. Until the relevant insurance company accepts the claim, no medical expenses are payable.

It is extremely important to note that the items able to be charged and the amounts will vary significantly from Medicare. Third party accounts will be charged according to the current Australian Medical Association Schedule of Fees or as arranged privately with an insurer or employer.


<Option 1>

This practice will directly bill the relevant insuring organisation once a claim has been lodged.

It is the responsibility of the worker to lodge the initial claim and obtain the claim record number. This will be included on all patient invoices.

Once this is done, the appropriate item number is selected, and a tax invoice is generated charging the patient’s care to the appropriate insuring organisation.

The following information will need to be included on the tax invoice:

Practice details including ABN Patient’s name Patient’s date of birth Claim number Description, Medicare item number and fee for the service rendered Account due date Payment facilities (direct deposit details etc)

<Option 2>

This practice considers it to be the responsibility of the injured worker to pay all of our fees, and then lodge an insurance claim with their employer. We consider we have a contract between the practice and the injured worker. As such, all workers compensation claims are handled the same way as ordinary patients and the normal billing requirements will apply.




1.1.25. Medical examinations not covered by MedicareSeveral services may be requested by patients that are not allowable to be billed to Medicare. Such services include practice consumables, pre-employment medical examinations and reports, commercial driving licence assessments, diving and aviation medicals. Third party accounts will be charged according to the current AMA Schedule of Fees or as arranged privately with an insurer or employer.

The doctor will inform the administrative staff if the consultation cannot be bulk billed and if the invoice is to be sent to a third party such as insurer or employer or paid privately by the patient. If the invoice is for practice consumables such as dressings or bandages, the patient will be made aware that there is no Medicare rebate available for those items.

1.1.26. Pre-employment medicalsMany industrial employers require pre-employment medicals to assess fitness to work or continue working in a role. Some will provide template forms for completion. A longer appointment and time with the nurse is often required in order to complete a full medical examination. Blood and urine tests may be required, as will an ECG and audiometry testing.

These requests cannot be charged to Medicare. Pre-employment medicals (third party accounts) will be charged according to the current AMA Schedule of Fees or as arranged privately with an employer.


<Option 1>

This practice will directly bill the relevant insuring organisation once an examination has been completed.

Once this is done, the appropriate item number is selected, and a tax invoice is generated charging the patient’s care to the appropriate organisation.

The following information will need to be included on the tax invoice:

Practice details including ABN Patient’s name Patient’s date of birth Claim number (if applicable) Description, Medicare item number and fee for the services rendered Account due date Payment facilities (direct deposit details etc)

<Option 2>

This practice considers it to be the responsibility of the worker to pay all of our fees, and then lodge a claim with their employer. We consider we have a contract between the practice and the worker. As such, all invoices are handled the same way as ordinary patients and the normal billing requirements will apply.




1.20. Costs of other health servicesOur medical practitioners will advise patients of the potential for out-of pocket expenses such as when undergoing further treatment, visiting specialists and allied health practitioners or having diagnostic imaging or pathology testing.

Our practitioners are not expected to know exact costs but will recommend that patients check with the provider when booking their appointment.

The medical practitioner will also consider alternative referrals to public health services if costs are considered a barrier to treatment.




9. HEALTH PROMOTION AND PREVENTATIVE CARE (CRITERION 1.3.1)

Policy

Our practice provides health promotion, illness prevention and preventive care and a reminder system based on patient need and best available evidence.

1.21. Health promotion activitiesOur practice recognises the integral part that general practices play in the coordination of health promotion and preventive care objectives in conjunction with other health professionals and key agencies.

We aim to provide a holistic approach to health care, allowing for each patient’s individual circumstances to be considered when providing health promotion, preventive care, early detection and intervention.

Health promotion activities in the practice assist the patient and promote patient proactivity towards health care and management. This results in patients increasing their preventive health appointments within the practice.

Health promotion activities that our practice regularly engages in include:

information on waiting room or community pin up boards

leaflet handouts

awareness raising on specific health areas using the WA Health Department What’s on in Health calendar for health topic ideas

feature of a health topic for one week of each month or every second month. Activities commence one month prior to the ‘feature’ week

contact with other relevant organisations for resources and promotional materials for distribution (such as pamphlets and posters)

‘theming’ the practice – for example, red balloons for heart awareness week; pink for breast cancer awareness

patient involvement – for example, the heart foundation jump rope for kids program or community walking challenges

contact with our Medicare Local to interact with the programs they have on offer

Current information on health promotion activities and support services within our local community are available in the waiting room and in each doctor’s consulting room.


The Western Australian Department of Health operates the What’s on in Health calendar. This can be found at http://www.whatson.health.wa.gov.au/.



http://www.whatson.health.wa.gov.au/


1.22. Preventative careOur practice provides health promotion, illness prevention, preventative care and a reminder system based on patient need and the best available evidence.

Our systematic approach to preventative care includes:

1.1.27. Vaccination and occupational health clinicsOur practice will:

Set up and promote influenza vaccinations on Saturday mornings (in season).

Coordinate with local employers to vaccinate their workforce against influenza in an effort to reduce sick days.

Offer occupational health services, for example, pre-employment screenings, hearing tests, workplace health assessments and visit the workplace to conduct basic health checks such as BMI, blood pressure, blood glucose levels, resting heart rate.

1.1.28. Mole scan unit Our practice will:

<Promote the availability of the mole scan unit (if available).>

Set aside a half day a week for a month and promote this time as skin check.

Promote 18–24 November as National Skin Cancer Awareness Week.

The Cancer Council of WA offer health professional resources to promote skin checks and sun safety, contact them for promotional gear such as posters http://www.cancerwa.asn.au/professionals/.

1.1.29. Asthma awarenessOur practice will:

Promote 1 – 7 September as national asthma week.

Promote this week as the time for Asthma patients to come in for a Chronic Disease Management Plan (CDMP) or a CDMP review (if applicable).

Utilise Asthma WA’s (www.asthmawa.org.au) range of resources available for health professionals and their patients including action plans and handbooks.

If not already registered, contact the Medicare Practice Incentives Program (PIP) and register for the Asthma incentives. PIP payments are available for sign on and service incentives.



http://www.asthmawa.org.au/


1.1.30. Seasonal ‘flu clinicsOur practice will follow the Australian Government Department of Health recommendations and promote the free flu vaccine to at-risk patients including:

Over 65’s

Aboriginal and Torres Strait Islanders 15 years and above

Pregnant women

Anyone over 6 months of age with:

Heart disease Severe asthma Chronic lung condition Chronic illness requiring medical follow-up or hospitalisation in the past year Diseases of the nervous system Impaired immunity Diabetes Children aged 6 months to 10 years who are on long-term aspirin therapy

For more information on Australian Government funded flu vaccines, please see:

http://ww2.health.wa.gov.au/Articles/F_I/Influenza-immunisation-program



http://ww2.health.wa.gov.au/Articles/F_I/Influenza-immunisation-program


1.23. Health risk assessmentsOur practice promotes participation in early detection screening programs such as the:

National Cervical Screening Program

BreastScreen Australia

National Bowel Cancer Screening Program

1.24. Managing patient information to support preventative careMembers of our clinical team routinely collect information that is transferred to a patient’s health summary. A complete health summary makes a useful statement of the patient’s main health issues. This contributes to better continuity of care within the practice and when patients seek care in other settings.

Some information may also be transferred to national registers (eg immunisation data) or state and territory based systems (eg cervical screening or familial cancer registries) in order to improve care.

Where the practice participates in national registers, patients are required to provide consent for the transfer of related health information to a register or be made aware that they can opt out of such registers.


Practice management, Chapter 4 - Confidentiality and privacy




1.25. Clinical resources for the practice – preventative health Useful resources for the practice:

PrimaryCare Sidebar® is an electronic platform that can host a range of products including prompts which notify general practitioners of follow up activities required. The PrimaryCare Sidebar® has add-ons including the RACGP Guidelines for preventive activities in general practice (the ‘e-red book’). This means the general practitioner is automatically notified about which preventive care activities are outstanding, up-to-date or unknown for the patient record that is opened. The preventive activities are based on the latest evidence based recommendations from the e-red book. Further information is available at www.pencs.com.au/products/primarycare-sidebar.

RACGP Guidelines for preventive activities in general practice (the ‘red book’) are available at www.racgp.org.au/guidelines/redbook.

RACGP Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (the ‘green book’) is available at www.racgp.org.au/greenbook.

RACGP Smoking, Nutrition, Alcohol and Physical Activity (SNAP) framework for general practice is available at http://www.racgp.org.au/your-practice/guidelines/snap/

RACGP learning modules are available at http://www.racgp.org.au/your-practice/business/managementtoolkit/

Australian absolute cardiovascular disease risk calculator is available at www.cvdcheck.org.au.

Information on cancer screening is available at www.cancerscreening.gov.au.

The National Preventative Health Strategy launched in 2009 includes technical papers on obesity, tobacco control and the prevention of alcohol related harm and can be found at http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp

The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) is an evidence based diabetes risk assessment tool that can directly link into the provision of a lifestyle modification program for patients who are found to be at risk of diabetes. The tool is available at www.health.gov.au/preventionoftype2diabetes.



http://www.health.gov.au/preventionoftype2diabetes

http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp

http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp

http://www.cancerscreening.gov.au/

http://www.cvdcheck.org.au/

http://www.racgp.org.au/your-practice/business/managementtoolkit/

http://www.racgp.org.au/your-practice/guidelines/snap/

http://www.racgp.org.au/greenbook

http://www.racgp.org.au/guidelines/redbook

http://www.pencs.com.au/products/primarycare-sidebar


10. CONSISTENT EVIDENCE BASED PRACTICE (CRITERION 1.4.1)

Our practice has a consistent approach for the diagnosis and management of conditions affecting patients in accordance with best available evidence.

1.26. Clinical practice guidelinesOur clinical teams will maintain up-to-date knowledge of current clinical practice guidelines to assist in the diagnosis and management of our patients by:

Regularly attending Continuing Professional Development activities

Utilising clinical software installed on the practice computers

Attending face-to-face clinical meetings

Access and utilising clinical guidelines for patients who identify as Aboriginal or Torres Strait Islander




1.27. Clinical resources for the practice – evidence based practice Known and trusted resources will be used for reference and clinical care guides. These include:

Australian Commission on Safety and Quality in Health Care Ensuring Correct Patient, Correct Site, Correct Procedure Protocol at www.safetyandquality.gov.au/our-work/patient-identification/patient-procedure-matching-protocols/ensuring-correct-patient-correct-site-correct-procedure-protocol/

Australian Medicines Handbook at www.amh.net.au

Australian Prescriber at https://www.nps.org.au/australian-prescriber

Central Australian Rural Practitioners Association (CARPA) treatment and reference manuals at http://www.remotephcmanuals.com.au/about_CPM.html

Cochrane library at www.thecochranelibrary.com/view/0/index.html

Diabetes Australia at www.diabetesaustralia.com.au

National Aboriginal Community Controlled Health Organisation (NACCHO) at www.naccho.org.au

National Asthma Council at www.nationalasthma.org.au

National Health and Medical Research Council at www.nhmrc.gov.au/guidelines/index.htm

National Heart Foundation at www.heartfoundation.com.au

National Prescribing Service at www.nps.org.au

RACGP Guidelines for preventive activities in general practice (the ‘red book’) at www.racgp.org.au/guidelines/redbook

RACGP Medical care of older persons in residential aged care facilities (‘silver book’) at www.racgp.org.au/guidelines/silverbook

RACGP Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting (the ‘green book’) at www.racgp.org.au/greenbook

RACGP Smoking, Nutrition, Alcohol and Physical Activity (SNAP) framework for general practice at http://www.racgp.org.au/your-practice/guidelines/snap/

Rational Assessment of Drugs and Research (RADAR) at https://www.nps.org.au/radar

Royal Children’s Hospital Melbourne clinical guidelines at www.rch.org.au/clinicalguide

Therapeutic Guidelines at https://tgldcdp.tg.org.au/etgcomplete?sectionid=71



https://tgldcdp.tg.org.au/etgcomplete?sectionid=71

http://www.rch.org.au/clinicalguide

https://www.nps.org.au/radar

http://www.racgp.org.au/your-practice/guidelines/snap/

http://www.racgp.org.au/greenbook

http://www.racgp.org.au/guidelines/silverbook

http://www.racgp.org.au/guidelines/redbook

http://www.nps.org.au/

http://www.heartfoundation.com.au/

http://www.nhmrc.gov.au/guidelines/index.htm

http://www.nationalasthma.org.au/

http://www.naccho.org.au/

http://www.diabetesaustralia.com.au/

http://www.thecochranelibrary.com/view/0/index.html

http://www.remotephcmanuals.com.au/about_CPM.html

https://www.nps.org.au/australian-prescriber

http://www.amh.net.au/

http://www.safetyandquality.gov.au/our-work/patient-identification/patient-procedure-matching-protocols/ensuring-correct-patient-correct-site-correct-procedure-protocol/




1.28. Patient identification – prior to surgeryOur clinical staff will ensure all patients undergoing minor surgery and procedures within our practice rooms receive the correct procedure.

Our practice incorporates the former Australian Commission on Safety and Quality in Health Care Ensuring Correct Patient, Correct Site, Correct Procedure Protocols into our standard processes for checking the identity of a patients and matching that identity to the correct procedure.

The five protocols are:

Days to hours before the procedure

Step 1: Complete a consent form or procedure request form.

Step 2: Mark the site of the invasive procedure.

Just before entering the operating theatre or treatment room

Step 3: Have the patient confirm their patient name, date of birth and site for, or type of, procedure.

Immediately prior to the procedure

Step 4: Team ‘time out’ – verbally confirm presence of the correct patient, that the correct site has been marked, the procedure to be performed and the availability of correct implant where required.

Step 5: Imaging data – if imaging data is used to confirm the site or procedure, two or more members must confirm the images are correct and properly labelled.

The Ensuring Correct Patient, Correct Site, Correct Procedure Protocol kit contains workplace posters and patient brochures. It also includes a fact sheet which our practice distributes to patients.

More information is available at:

If time is money – poster www.safetyandquality.gov.au/wp-content/uploads/2012/02/timingposter.pdf

Ensuring Correct Patient, Correct Site, Correct Procedure www.safetyandquality.gov.au/wp-content/uploads/2012/02/ensureposter.pdf

Ensuring Correct Patient, Correct Site, Correct Procedure Fact Sheet www.safetyandquality.gov.au/wp-content/uploads/2012/02/factsheetb.pdf

Patient Brochure – Understanding your procedures www.safetyandquality.gov.au/wp-content/uploads/2012/02/patbrochp.pdf

Patient Brochure – Understanding your surgery www.safetyandquality.gov.au/wp-content/uploads/2012/07/understandingyoursurgery.pdf



http://www.safetyandquality.gov.au/wp-content/uploads/2012/07/understandingyoursurgery.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/patbrochp.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/factsheetb.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/ensureposter.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/ensureposter.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/timingposter.pdf


1.29. Health inequalities Our practice team recognises that nationally there are some significant differences in key indicators of general health and wellbeing. This information highlights the need for primary healthcare interventions tailored to specific groups within the Australian community.

We understand that health gains have not been equally shared across all sections of the population and today Australia is characterised by large morbidity and mortality inequalities between population subgroups.

This includes homeless youth, children of single parent families, people with developmental disabilities, Aboriginal and Torres Strait Islander people, refugees and those from culturally and linguistically diverse populations.

For example, the Australian Institute of Health and Welfare (AIHW) report, Australia’s Health 2010 (available at www.aihw.gov.au/publication-detail/?id=6442468376 ) identifies that Aboriginal and Torres Strait Islander people have a life expectancy that is significantly less than that of other Australian men and women.

In an effort to combat these inequities, our staff will accommodate the specific health needs of individuals who may be suffering disadvantage.

Resources related to managing the chronic health conditions of Aboriginal and Torres Strait Islander people are available at:

Australian Indigenous HealthInfoNet www.healthinfonet.ecu.edu.au


Practice services, Chapter 17.3 - Recording cultural background Practice services, Chapter 17.4 - Recording Aboriginal and Torres Strait Islander status



http://www.healthinfonet.ecu.edu.au/

http://www.aihw.gov.au/publication-detail/?id=6442468376


1.30. Consistent communication With our patients

Our practice team understands the importance of a consistent approach to all communication, treatment and clinical care of our patients.

For our patients to have confidence in our systems and trust in our medical practitioners it is imperative that all staff work in accordance with the same policies and procedures and that clinical care is consistent with the best available evidence.

With the clinical team

In order to achieve a consistent approach to clinical care, our practice staff will record detailed patient records and provide handover notes between doctors and other clinical staff members.

Records will be precise and have a clear plan for the patient’s care.

Our team has regular <detail regularity> clinical team meetings to discuss interesting or difficult cases and comprehensive management of patients. This is particularly important for our registrars and non-vocationally recognised medical practitioners working towards Fellowship exams or under supervision and mentorship of our clinical team leaders.




11. CLINICAL AUTONOMY FOR GENERAL PRACTITIONERS (CRITERION 1.4.2)

Our practice ensures that all general practitioners in our practice can exercise autonomy in decisions that affect clinical care.

1.31. Clinical autonomy within evidence based careOur general practitioners are free, within the parameters of evidence based care, to determine:

The appropriate clinical care of patients

The specialists and other health professional to whom they refer

The pathology, diagnostic imaging and other investigations they order and the provider they use

How and when to schedule follow up appointments with individual patients

Whether to accept new patients

Members of our clinical team are also consulted about the length and scheduling of appointment times and team discussions are held to discuss the purchases of new clinical equipment and supplies.

1.32. Professional and ethical obligationsAll members of our clinical team will comply with the professional and ethical boundaries required by law, their boundaries of knowledge, skills and competence and their associated professional organisations such as:

Australian Health Professional Regulation Authority (AHPRA)

Royal Australian College of General Practitioners (RACGP)

Australian College of Rural and Remote Medicine (ACRRM)

Australian Medical Council (AMC)

Australian Medical Association (AMA)


Practice services, Chapter 1.5.2 - Staff code of conduct




12. CONTINUITY OF COMPREHENSIVE CARE AND THE THERAPEUTIC RELATIONSHIP (CRITERION 1.5.1)

Policy

Our practice provides continuity of comprehensive care to our patients

1.33. Provider continuity and patient outcomesThe RACGP defines general practice as providing patient centred, continuing, comprehensive, coordinated primary care to individuals, families and communities.

Our practice understands that patient trust and confidence is built over time and as such encourages patients to receive ongoing care from the same doctor. Our staff will check with the patient who their normal doctor is each time the patient presents for an appointment.

Our practice will encourage the attendance of a patient with their regular general practitioner in order to maintain a trusting, continuing, comprehensive and coordinated cycle of care.

In the case of the patient’s usual doctor being unavailable, staff will offer an appointment with an alternative doctor at this practice. All doctors in this practice, including locums, keep accurate records and important updates are passed directly to the usual doctor.

Provision of after-hours service to ensure continuity of care is detailed in sections:

Practice services, Chapter 3 - Home and other visits Practice services, Chapter 4 - Care outside normal opening hours

In the event of a patient leaving this practice, or transferring to another practice, this practice will assist in continuity of patient care by forwarding a copy or summary of the records to the new practitioner.


Practice services, Chapter 13.3 - Transfer of health information – To another practice

This practice does not deny access to any patient on the basis that the doctors may or may not specialise in the area of the patient’s medical condition. Should a patient present with a condition where the appropriate management is not within the capacity of this practice, they will be referred to an appropriate provider.




1.34. The doctor patient relationshipOur medical practitioners value the patient doctor relationship and will acknowledge the rights of patients to question or discuss the provider’s referrals or treatments and to make decisions about their own healthcare.

Our medical practitioners may refer our patients to read a copy of the former Australian Council for Safety and Quality in Health Care publication, 10 tips for safer healthcare. A copy of the publication is available at:

www.safetyandquality.gov.au/wp-content/uploads/2003/01/Tips-for-Safer-Health-Care-PDF-302KB.pdf

If a patient is unable to be effectively treated by a doctor in this practice for various reasons, including lack of rapport, the doctor will make every effort to locate another doctor to undertake the care of this patient.

1.35. Courtesy notificationsWhere a medical practitioner ceases or will cease practise within our general practice, our team members will make an effort to advise the medical practitioners’ regular patients of this change.

If desired, patients will be given information on how to request a transfer of medical records.


Practice services, Chapter 13.3 - Transfer of health information – To another practice






1.36. Supporting preferred relationshipsOur practice team supports preferred professional relationships between our patients and our clinical team.


<Option 1>

To support preferred relationships, our practice has a formal appointment booking system, using our practice software system <insert name of software>.

Patients are able to book an appointment to see their doctor of choice in accordance with our appointment triage system:

urgent care;

non-urgent care;

complex care;

planned chronic disease management;

preventative health care; and

long consultations.

<Option 2>

Our practice has a walk in policy for seeing the doctor.

On arrival walk in patients are assessed for clinical needs such as:

urgent care;

non-urgent care;

complex care;

planned chronic disease management;

preventative health care; and

long consultations.

Walk in patients may see the Aboriginal health worker or practice nurse for baseline assessment prior to seeing the next available doctor. Patients wishing to see a particular doctor will be advised by practice staff of the approximate waiting time.


Practice services, Chapter 1 - Scheduling care in opening hours




13. CLINICAL HANDOVER (CRITERION 1.5.2)

Policy

Our practice has an effective clinical handover system that ensures safe and continuing healthcare delivery for patients.

1.37. Defining clinical handoverThe Australian Medical Association defines clinical handover as ‘the transfer of professional responsibility and accountability for some or all aspects of a patient’s or a group of patients’ care to another person or professional group on a temporary or permanent basis’.

Clinical handover needs to occur whenever there is an interface of care by different individuals, groups or providers.

Examples of clinical handover include:

A general practitioner covering for a fellow general practitioner who is on leave or is unexpectedly absent.

A general practitioner covering for a part-time colleague.

A general practitioner handing over care to another health professional such as a practice nurse, physiotherapist, podiatrist or psychologist.

A general practitioner referring a patient to a service outside the practice.

A shared care arrangement (eg team care of a patient with mental health problems).

Our staff recognise the potential consequences of poor handover which can include:

unnecessary delays in diagnosis, treatment and care;

repeated tests, missed or delayed communication of test results; and

incorrect treatment or medication errors.

During handover our clinical staff will:

transfer all relevant data;

be accurate and unambiguous; and

provide the information in a timely manner.




1.38. Clinical handover actionsThe National Safety and Quality Health Standards (2012) tell us that clinical handovers can vary depending on patient circumstances, including:

The situation of handover, such as

During a shift change

When patients are transferred inter and intrahospital

During patient admission, referral or discharge

The method of handover, such as

Face-to-face

Via telephone

Via written orders

When aided by electronic handover tools

The venue where handover takes place, such as

At the patient’s bedside

In a common staff area

At a hospital or clinic reception

Recommendation: A team planning session with doctors and staff to evaluate past systems and to ensure that they fit the effective, fail-safe and sustainable criteria including:

Clinical handover within the practice

Clinical handover outside the practice

When shared care ceases

Medical deputising services

Clinical handover to an emergency department

Handover of tests and results

References and further resources:

Clinical Handover Fact Sheet. Australian Commission of Safety and Quality in Healthcare: NSQHS Standards. www.safetyandquality.gov.au www.safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-6.pdf

Safe Handover: Safe Patients. Australian Medical Association. 2006 https://ama.com.au/sites/default/files/documents/Clinical_Handover_0.pdf

National Safety and Quality Health Service Standards. Australian Commission on Safety and Quality in Health Care www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf



http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf

https://ama.com.au/sites/default/files/documents/Clinical_Handover_0.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-6.pdf

http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-6.pdf

http://www.safetyandquality.gov.au/


1.39. Transfer of patient health information to another practiceTransfer of medical records from this practice can occur in the following instances:

When a patient asks for their medical record to be transferred to another practice.

For medico-legal reasons, eg record is subpoenaed to court.

Patient presents for consultation at our branch practice. The record is requested from that branch via telephone/fax/email. When a doctor is to consult at that branch for the next session he/she will take the record with them on the visit/or we use a confidential courier service.

Where an individual medical record report is requested from another source.

Prior to forwarding a copy or summary of the medical record to the requesting organisation, our practice staff will ensure that the patient has provided the practice with a signed document indicating their consent.

If a photocopy of the medical record is beging sent, stamp or record “COPY” on each page.

Our practice will record a copy of the requesting letter and the patient’s consent to the medical records held at our practice.

A copy of the requesting letter and the patient’s consent will also be attached to the records sent to the requesting organisation.

Medical records will only be sent via:

Registered post The patient Confidential courier service with a fee indicated (if applicable)


<Option 1>

When a patient asks for their medical record to be transferred to another practice, written consent must be obtained from the patient prior to the transfer.

Upon consent, this practice will forward a photocopy or summary report to the requesting practice free of charge.

<Option 2>


Upon consent, this practice will forward a photocopy or summary report to the requesting organisation with a fee indicated.

<Option 3>


Upon consent, this practice will forward a photocopy or summary report to the requesting organisation only after a fee has been paid.




1.40. Transfer of patient health information – from another practiceAt times, it is necessary for a doctor to become familiar with a new patient’s medical history via their medical record from a previous practice. If a copy or summary of a medical record is required, written patient consent is essential before the transfer of records proceeds.

Ask the patient to complete the Request to Transfer Medical Records Form indicating consent for their previous practice to forward a copy or summary of their medical record.

Send a letter to the previous practice requesting that they provide a copy or summary of the patient’s medical record and enclose the original copy of the patient’s consent.

Prior to sending the request, photocopy the letter and consent from the patient and attach it to the patient’s new medical record.

1.41. Errors in clinical handoverOur practice nurtures a culture of just and open communication to support the resolution of errors in clinical handover.

When errors or near-misses occur in clinical handover, every member of the practice team is encouraged to report the circumstance using de-identified data, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients.


Safety, quality improvement and education, Chapter 2 - Clinical risk management systems




14. FOLLOW UP OF TESTS AND RESULTS (CRITERION 1.5.3)

Policy

Our practice has a system for the follow up and review of tests and results.

Clinically significant tests and results are followed up.

Patients are made aware of the seriousness of not attending for follow up.

Patients are made aware of who is responsible for communicating with whom about results and when this is to occur.

1.42. DefinitionsThe RACGP Standards for General Practices: Fourth edition, defines the following:

‘Follow up’ can mean:

Following up the information – following up on tests and results that are expected but have not yet been received by the practice.

Following up the patient – tracing the patient to discuss the report, test or results after they have been received by the practice and reviewed, or tracing the patient if the patient did not take a test as expected.

‘Recall’ means:

A system to make sure patients receive further medical advice on matters of clinical significance.

‘Clinical significance’ is determined by: The probability that the patient will be harmed if further medical advice is not obtained The likely seriousness of the harm.

A ‘follow up system’ is required by the practice to ensure that:

All received test results and clinical correspondence (eg. reports from other healthcare providers) relating to a patient’s clinical care are reviewed.




1.43. Essential follow up systemsThis practice appreciates the need for a team based approach when coordinating the recall and reminder system which includes defining the role of the clinical and administrative staff to ensure that the system is effective, fail-safe and sustainable.

When using electronic recall and reminder systems it is acknowledged that the data is only as good as what is entered. This reinforces the need to have adequate systems, policies and procedures in place.

Recommendation: A team planning session with doctors and staff to evaluate past systems and to ensure that they fit the effective, fail-safe and sustainable criteria including the following:

Communicating tests and results to patients (abnormal and normal)

Patients’ obligations

Where a recommended test is refused

Timely review and action on tests and results

Systems for tracking tests sent and received by the practice

Medical practitioner review of every test, result and letter (signed and dated)

Establishing a ‘buddy’ system to cover periods of leave




1.1. Receiving incoming results and reportsAll incoming pathology results, imaging reports, investigation reports and clinical correspondence received by or performed in our practice will be:

Reviewed by a general practitioner

Signed or initialled or electronic equivalent

Dated

Where appropriate, acted upon in a timely manner

All actions relating to patient results will be recorded in the patient’s notes. The staff member who telephones the patient or carries out any other follow up action is responsible for recording the details.


<Option 1> Computerised

Incoming results, letters, images are downloaded according to the service provider instructions <when and how many times per day>.

The doctor is to review, electronically sign, date and record action on each piece of mail before marking as actioned.

Actions for follow up or reminders to be sent are undertaken by the practice nurse (see recalls and reminders).

<Option 2> Paper based

Separate the mail based on advertising, personal and patient information.

Stamp generic mail with the date stamp, recording the date that the mail was opened.

Imprint results and reports with a stamp containing the following prompts:

Date received and reviewed Date results reviewed by doctor Initials of doctor Follow up action to be taken by staff

Do not file test results until the above information is completed

Attach the results to the patient’s medical record.

Place the medical record with the attached results in the requesting doctors in tray (paper based filing) or place the results in the requesting doctor’s in tray (electronic based filing).

If the requesting doctor will not be in the practice in the next 24 hours, refer the results and file to another doctor for review.

Upon return of the file from the doctor, check the result for any actions that need to be carried out.

Actions for follow up or reminders to be sent are undertaken by the practice nurse (see recalls and reminders).

If all actions have been completed and recorded, file the results and the medical record.




1.1. Conducting a review of follow up systemsA suggested plan for the review is as follows.

Appoint a recall and reminder coordinator.

Review existing system (if applicable) and determine whether or not it is effective, fail-safe, and sustainable.

If it does not meet the above criteria, determine why it does not and how it can be improved.

For reminder systems, agree on the clinical areas that the practice will focus on for using the reminder system, eg diabetes, chronic disease management, pap smears, immunisation.

Determine whether the reminder reasons, ‘pick-lists’, diagnoses and condition in the clinical software meet the practices’ needs.

If no, brainstorm to complete a list of additional reminder reasons, diagnoses and conditions and arrange for the recall and reminder coordinator to add these to all computers with clinical software.

Determine and standardise what the recall and reminder letter says or what staff advise patients during a phone call and arrange for the recall and reminder coordinator to add the templates to all computers with clinical software and prepare a script for phone conversations for the practice staff.

Clarify the policy for methods and attempts to recall a patient based on continuous care and medico-legal implications. For example:

Three (3) phone calls at different times of the day. If the patient has not responded, send a letter via registered post.

Clarify the policy for methods and attempts to remind a patient based on continuous and preventative care. For example:

Two (2) letters marked private and confidential. If the patient has not responded to the letter, make a phone call.

Determine the methods of patient education regarding the practices’ recall and reminder system. For example:

Sign or pamphlet in the waiting room Statement in the patient information sheet Verbal advice from the doctor Verbal advice from the practice staff




1.1.31. The general practitioner and the reminder systemEstablish the role of the general practitioner with regard to the reminder system. For example, the general practitioner:

Advises the patient that a reminder system is available and the reason why they should be on the list.

Secures consent from the patient – this could be implied or expressed.

If applicable, general practitioners ask the patient the preferred means of receiving the reminder.

Marks in the medical record that the patient is to be reminded in “2 years” to come back to the practice for a “pap smear”.

Makes notation in the medical record that consent has been received.

Opportunistically checks patient medical record when they come in for an appointment to see if they are due for another test.

Updates or removes reminders from the list as required or when the patient has been seen.

1.1.32. Practice staff and the reminder systemEstablish the role of the practice staff with regard to the reminder system. For example, practice staff will:

On a monthly basis review the reminder system list for a one-month period

Check with the doctor to see if patients should be removed or added to the list

Send reminders to the patients via the determined method of communication

Make a notation in the medical record regarding first, second or third reminder, method of communication, date communication was made and other notes, such as whether they spoke to the patient

Inform all new patients that the practice has a reminder system and to discuss it with their doctor if they would like to know more

Routinely confirm the patient’s phone number when they make an appointment and confirm the patient’s home address when they visit the surgery to ensure that their details remain accurate and up-to-date

If the patient has not responded to the communications, the practice staff will inform the doctor and ask for appropriate action




1.1.33. The general practitioner and the recall systemEstablish the role of the general practitioner with regard to the recall system. For example the general practitioner:

Enters into the patient’s medical record that they are to be recalled and the level of urgency for contact.

Updates or removes recalls from the list as required or when the patient has been seen.

1.1.34. Practice staff and the recall systemEstablish the role of the practice staff with regard to the recall system. For example, practice staff will:

On a daily basis check the recall system for patients that need to be contacted

Attempt to contact the patient via the determined method of communication

Made a notation in the medical record regarding first, second or third reminder, method of communication, date communication was made and other notes, such as whether they spoke to the patient

Routinely confirm the patient’s phone number when they make an appointment and confirm the patient’s home address when they visit the surgery to ensure that their details remain accurate and up-to-date

Action the above and determine whether any training is required for doctors and staff

If the patient has not responded to the communications within <<insert period>>, the practice staff inform the doctor and ask for appropriate action




1.19. Issuing recallsOn the receipt of an abnormal test result, patients will be contacted by the practice for a follow-up appointment. The doctor or the practice nurse will inform the patient of the result during the appointment and any subsequent consultation or other action required. All attempts will be made to contact the patient so that an appointment can be made to discuss the results.

It is the responsibility of the <person responsible for the recall system> to review and action the reminder system on a <frequency of recall system> basis.

As a minimum, this practice will attempt to contact the patient via the following methods:

Three (3) phone calls at different times of the day.

If the patient has not responded, then a letter will be sent via registered post asking the patient to contact the practice.

Patients who need to be informed of further action, for example as a once off follow up for repeat pap smear or on a regular basis such as a monthly blood test, form part of our reminder system.

All attempts to contact the patient will be documented in their medical record.

Follow procedures for opening and disseminating results and reports as detailed in:

Practice services, Chapter 14.2.2 Receiving incoming results and reports

When the doctor returns the results, follow the instructions provided. This may entail contacting the patient to make an appointment with the doctor or putting them through to speak with the doctor or advising the patient over the phone that their results are normal.

IMPORTANT NOTE: Prior to contacting the patient, cross reference their file to check for notations and also to make sure that they have not already received the information.

If contacting the patient to make an appointment to see the doctor, make three (3) phone calls at three different times of the day. Document in the patient’s medical record all attempts to phone them and the times of the day called.

If the patient does not respond, send a letter via registered post asking the patient to contact the practice. Document in the patient’s medical record the date that you sent the letter and the registered post details.

IMPORTANT: Do not remove the recall flag until the patient has ATTENDED their appointment.

If the patient does not attend, advise the doctor and repeat the above procedures.

Once the patient has their appointment and the doctor has actioned the results and initialled the original, remove the recall flag, file the report and then file the medical record.




1.20. RemindersReminders are conducted for immunisation, pap smear, cancer follow up, blood tests for certain conditions, annual medical checks for over 75’s and as advised by a doctor for other defined situations. The doctor will advise reception of patients who need reminders or they will flag it in the patient’s medical record.

If using a card-based system, receptionists are to record the name, date of recall and in the reminder diary under the date due.

It is the responsibility of the <person responsible for the reminder system> to review and action the reminder system on <frequency of reminder system> basis.

Doctors are to seek a patient’s consent for a reminder notification. This consent is noted in the patient’s medical record.

All attempts will be made to contact the patient so that an appointment can be made to conduct a routine health check, blood test or other defined situation. As a minimum, this practice will attempt to contact the patient via the following methods:

Two letters will be forwarded, marked private and confidential.

If the patient does not respond, then a reminder phone call will be made.

All attempts to contact the patient will be documented in their medical record.

On a monthly basis, generate the reminder letter to the patient. Document in the patient’s medical record the date that the first letter was forwarded to the patient.

IMPORTANT NOTE: Prior to contacting the patient, cross reference their file to check for notations and also to make sure that they have not already received the information.

If the patient does not contact the practice after the first letter, send a second letter the next month. Document in the patient’s medical record the date that the second letter was forwarded to the patient.

If the patient does not contact the practice after the second letter, phone the patient. Document in the patient’s medical record all attempts to phone them and (if applicable) the times of the day called.

IMPORTANT: Do not remove the reminder flag until the patient has ATTENDED their appointment.

If the patient does not attend, advise the doctor and repeat the above procedures.

Once the patient has their appointment, remove the reminder flag and file the medical record.




1.44. Errors in follow-up Our practice nurtures a culture of just and open communication to support the resolution of errors in follow-up.

When errors or near-misses occur in follow up, every member of the practice team is encouraged to report the circumstance using de-identified data, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients.


Safety, quality improvement and education, Chapter 2 - Clinical risk management systems

1.45. Sending letters to patientsAll letters sent to a patient’s home or other contact address will be sent in non-identifiable envelopes to preserve privacy and confidentiality, ie no practice logos on the envelope and preferably a PO Box only for a return address.

This includes:

Invoices and receipts

Reminders

Recalls

Copies of results

Any other communication




15. ENGAGING WITH OTHER SERVICES (CRITERION 1.6.1)

Policy

Our practice engages with a range of health, community and disability services to plan and facilitate optimal patient care.

It is the policy of this practice that all staff members are aware of local health and other community services in this area. This practice works with these services as required facilitating optimal patient care.

1.1. Patient resourcesThis practice has the following resources available for patients:

Health and community information for patients

Practice notice board

Health promotion material

Community resource directory

Library – books, tapes and videos

Computer generated health promotion material

Consumer product information

Telephone book


1.2. Staff resourcesThis practice has the following resources available for staff members:

Health and community information for patients

Community resource directory

Reference material – books, videos, computer software, and journals

Details on local allied health professionals

Details on local diagnostic services

Details on local pathology services

Doctors/specialists listings

AMA Membership

RACGP Membership

Yellow Pages

Local Medical Specialist Centres and Hospitals





1.3. Location of resourcesHealth and community information is stored in:

<location of health and community information for doctors and staff>

Reception

Consulting room

Treatment room

Computer system

Kitchen/tea room

It is the responsibility of <position responsible for maintaining health and community services information> to maintain the health and community service resources for both patients and general practitioners and staff of the practice.




16. REFERRAL DOCUMENTS (CRITERION 1.6.2)

Cross references with patient identification (Criterion 3.1.4)Policy

Our referral documents to other health care providers contain sufficient information to facilitate optimal care.

1.46. Unique patient identifiersAt each encounter with our practice team, our patients will be correctly identified.

Our clinical referral documents and letters will include a set of approved patient identifiers including:

Name

Address

Date of birth

Gender

Patient record number where it exists

Our staff will cross reference incoming letters and referrals to ensure the correct patient is identified.

A Medicare number is not an approved identifier as more than one number may exist for a patient.

Our team will ask a patient to identify their own name, date of birth and address rather than volunteering the information from current records, each time they make an appointment. This activity will ensure all contact details are kept up-to-date.




1.47. Sufficient informationOur clinical referral documents will include relevant information to ensure:

The correct patient is being referred.

The person to whom the patient is referred receives sufficient and relevant information to manage the patient.

Patient confidentiality is preserved.

Referrals will:

Be printed or handwritten on appropriate practice stationery.

Include relevant history, examination findings and current management

Include a list of known allergies, adverse drug reactions and current medicines.

Appropriately identify the doctor making the referral.

Identify the healthcare setting from which the referral has been made.

Identify the healthcare setting to which the referral is being made.

Include, if known, the healthcare provider’s name to whom the referral is being made.

If the referral is sent electronically then it will be transmitted in a secure and encrypted manner in accordance with standards for the secure transmission of health information to avoid a breach of patient confidentiality.

A copy of any referral document will be retained in the patient health record.

1.48. Disclosure of patient informationOur patients are made aware that their patient health information is being disclosed in referral documents.

Our medical practitioners will consider on a case-by-case basis whether patients should be given the opportunity to read the content of the referral letter before it is forwarded to another care provider.

1.49. Telephone referralsTelephone referrals may be considered in the case of an emergency or other unusual circumstance. Any telephone referral will be documented in the patient’s health record.




17. PATIENT HEALTH RECORDS (CRITERION 1.7.1)

Policy

For each patient we have an individual patient health record containing all the health information held by our practice about that patient.

1.21. Dedicated patient health recordsThis practice has a <completely paper based filing system/completely electronic filing system/hybrid or combination of paper and electronic filing system>.Patient health records are a legible, detailed, confidential document compiled by a health professional, over a period of time, on a particular person. For each patient we have an individual patient health record containing all the health information held by our practice about that patient.

Our active patient health records will include patient identification, contact and demographic information (where appropriate) including:

The patient’s full name (surname and given name)

Date of birth


Contact details

The person our patients’ want contacted in an emergency

Aboriginal and Torres Strait Islander status

Other cultural backgrounds

The following guidelines are followed for maintaining security:

Practice records are to be maintained, handled and stored in a manner which will prevent:

Loss Breaches of confidentiality Unauthorised access

Maintain privacy/confidentiality from others (eg patients, public and staff) under all circumstances including patient:

Address Telephone number Results

Written/telephone requests – always follow the correct procedure.

Ensure appropriate disposal of documents including patient files, accounts and business records.

This practice maintains an accurate recording system to update and track files, especially changes of name or address. Correct disposal requirements must be observed.

Security is maintained for files at all times. During practice hours the file storage area is unlocked. At the end of the working day the practice manager, a doctor or delegated staff member locks the filing area.




1.1.35. Creating a new medical recordSelect the most appropriate option for your practice or create your own procedure.

<Option 1> Computerised

Collect patient name, address, date of birth and related demographic details.

Enter information on the computer as per software instructions held at <Instruction manual>

Inform the doctor that the patient is new to the practice.

<Option 2> Paper based

Collect patient name, address, date of birth and related demographic details.

Enter information on the patient master card index.

Obtain the next new number from the patient number index and record this patient number on the new patient record cover.

Place progress notes inside the medical record and inform the doctor that the patient is new to the practice.

1.1.36. Retention of records and archivingThis practice recognises the RACGP recommendations that an active patient is one who has attended the practice three or more times in the past two years. The practice regularly archives in-active patient records – whether paper or electronic. Patient account records are retained for seven years.

Adults

Medical records collected from adults will be retained for seven years after their last health service.

Children

Health information collected from children (ie under 18 years of age) will be retained until they reach 25 years of age or for seven years after their last health service whichever is the later.

Patients with a known psychiatric illness

The medical records of any patient treated for psychiatric illness are to be retained for a minimum of seven years following death.




1.1.37. Destruction of medical recordsRecords for the last <period of time files are kept in active storage> are kept in active storage, which is located at <location of active file storage>. Records of patients who have not presented to the practice for more than <period of active file storage> are located in Inactive storage which is located at <location of inactive file storage>.

Every <period of review of active records>, a record review is conducted for active records not accessed. These records are removed from active file and stored in the inactive file area. Patient accounts records are reviewed at the end of each financial year.

After seven years if an adult, or 25 years if a child, following the last occasion in which a patient presented for a consultation, the medical record will be destroyed.


<Option 1>

This practice disposes of confidential medical records and materials utilising the in-house shredder.

<Option 2>

This practice disposes of confidential medical records and materials utilising an outside service. This practice maintains a contract for this service.

Contact details for this provider are recorded in section:

Our practice, Chapter 3.1 - Business and service provider contacts

1.1.38. Collecting information from patientsAll new patients will be required to complete a NEW PATIENT QUESTIONNAIRE either by paper questionnaire or by private interview with a staff member prior to the first consultation.

Our practice will regularly review patient information on record so that it remains current and accurate.

Our staff will routinely record the person the patient would like contacted in an emergency.

At the time of making an appointment, all patients will routinely be asked to confirm their:

Full name (surname and given name)

Date of birth


Contact details (address and telephone)

Medicare card and Commonwealth Concession card (if applicable)




1.1.39. Recording cultural backgroundOur practice is working towards recording the cultural background of our patients.

Our practice will collect this information as part of the NEW PATIENT QUESTIONNAIRE and preface questions on cultural background by explaining that such information helps the practice provide appropriate healthcare.

Once the question has been asked, the response will be recorded in the patient record <in the following location> to ensure the question is not repeated.

1.1.40. Recording Aboriginal and Torres Strait Islander statusAll patients, irrespective of appearance, country of birth or whether the staff know of the client or their family background will be asked:

‘Are you of Aboriginal or Torres Strait Islander origin?’

Our practice will collect this information as part of the NEW PATIENT QUESTIONNAIRE and preface questions on cultural background by explaining that such information helps the practice provide appropriate healthcare.

Once the question has been asked, the response will be recorded in the patient record <in the following location> to ensure the question is not repeated.

An RACGP fact sheet is available at www.racgp.org.au/yourracgp/faculties/aboriginal/guides/identification/



http://www.racgp.org.au/yourracgp/faculties/aboriginal/guides/identification/


18. HEALTH SUMMARIES (CRITERION 1.7.2)

Policy

Our practice incorporates health summaries into active patient health records.

1.50. Health summaries for safe and high quality careA health summary will assist in reducing the risk of inappropriate management of our patients including medicine interactions and side effects, such as allergies.

Our health summaries will provide the social and family overview which is vital to whole patient care.

Our health summaries will include lifestyle problems, risk factors and preventative care status for all patients, including:

Currency of immunisations

Smoking status

Nutritional data

Alcohol intake

Physical activity

Blood pressure

Height and weight [body mass index]

Known allergies

Social history and recent important life events

1.51. Coding Our health professionals will use consistent coding of diagnoses when available (and discourages the use of free text descriptions in the health record). These will be used in the consultation notes to support continuous quality improvement of clinical care, patient outcomes and chronic disease management. Our practice uses nationally recognised coding system:


<Option 1>

Our clinical software program uses a default nationally recognised disease classification/terminology system which includes a ‘pick list’ or ‘drop down box’ function.

<Option 2>

<enter alternative nationally recognised disease classification/terminology system>




19. CONSULTATION NOTES (CRITERION 1.7.3)

Policy

Each of our patient health records contains sufficient information about each consultation to allow another member of our clinical team to safely and effectively carry on the management of the patient.

1.52. Consultation notes A consultation is defined as any interaction related to a patient’s health needs between our practice staff and a patient.

Our patient health records will include details of all clinical significant consultations including:

After-hours visits

Hospital visits

Home visits

Telephone and electronic communications

Our active patient health records and consultation notes will include current and past medical history including:

An alert notification for allergic responses and drug reactions is marked in the patient’s medical record

Any WorkCover or insurance information and relevant legal reports

Complementary medicines used by the patients

Consultation notes (including care outside normal opening hours and home visits)

Date of consultation

Diagnosis

Follow up of previous consultations

Investigations or referrals

Letters received from hospitals or consultants

Medical history

Medicines prescribed (including name, strength, directions for use, number of repeats and date medicine started/ceased/changed)

Other clinical correspondence

Reason for visit

Recommended management plan and where appropriate expected process of review

Referrals to other healthcare providers or health services

Relevant clinical findings

Relevant preventative care undertaken

Results

Special advice or instructions

Who conducted the consultation

