Accreditation practice pointer: follow up

C7.1 D Our patient health records show that matters raised in previous consultations are followed up.

RACGP Standards for general practice.

According to medical defence organisations, practices and practitioners are held to account when matters raised by patients are not followed up. In fact, clinicians must document matters that have been followed up in the patient health record to meet the Criterion.

Thorough and accurate patient health records and consultation notes encourage follow-up healthcare. Ultimately, this helps mitigate risks in primary healthcare.

General practice can promote follow-up care by maintaining a policy on the management of patient health information.

Furthermore, patient health records should include:

  • the recommended management plan and, where appropriate, expected process of review

  • any medicines prescribed for the patient (including the name, strength, directions for use, dose, frequency, number of repeats and date on which the patient started/ceased/changed the medication)

Using flags in the consultation notes to mark issues that need to be followed up is a practical way of ensuring thorough healthcare is provided.

Margot Schoonmaker