By Kathy Gough
Team Leader, Claims, Avant Mutual Group Limited
It’s a busy morning in your practice and Mrs R, your 10.30 appointment, presents complaining of sudden onset flashes of light in her right eye and she thinks there may be a shadow as well.
You immediately recognise the symptoms of a retinal detachment and set in motion an urgent referral to your nearest tertiary referral hospital. You carefully explain to Mrs R the seriousness of her condition and that it should be regarded as an emergency as it threatens her sight. Mrs R appears to understand and walks out the door, referral in hand.
Do you have a responsibility to follow up Mrs R?
This is a question often asked by health professionals, who frequently add the comment that surely a competent adult patient should be able to accept responsibility for following instructions or follow-up as advised by their health professional.
Optometrists do have a duty to exercise reasonable care and skill in the treatment of patients. This duty extends to the examination, diagnosis and treatment of the patient, provision of information and follow-up.
Case law regarding patient follow-up has centred on the follow-up of tests, and suggests that once the optometrist has undertaken tests or recommended a procedure or test the optometrist has a duty to:
• Take reasonable steps to remind the patient to have the recommended tests or procedures
• Follow up the results of tests he or she has recommended and the patient has undergone, and to advise the patient of the results of those tests.
Two cases in particular, Tai v Hatzistavrou (1999) NSWCA 306 and Kite v Malycha (1998) 71 SASR 321, suggest that lack of follow-up of a missed appointment not involving tests, but which had significant clinical implications, may be judged similarly by the courts.
Many optometrists feel that the onus of responsibility placed on them is too great and that the courts have inappropriately shifted patient responsibilities to clinicians.
It should be noted that the judgements made were very circumstance-specific. The duty is to exercise a level of care that is ‘reasonable in all the circumstances’, not perfect. The judgements also recognised that patients are responsible for their own actions, acknowledging that clinicians cannot compel a patient to attend a follow-up appointment.
According to Practice Standards published by Optometry Australia,1 it is important for patients to receive ‘sufficient information’ and ‘optimum care’.
Criterion 3.1.4 ‘Patients receive sufficient information to enable them to make informed decisions about their care’ when:
• Patients whose test results cannot be advised immediately in person are notified of the results by the optometrist in a timely manner and by a suitable means agreed to by the patient.
• Patients who do not attend a scheduled appointment are contacted by members of the practice team.
• Patients with a history of failing to attend appointments are contacted to remind them of an impending appointment.
Criterion 4.1.1 ‘Patients receive optimum care’ when the practice is required to follow up patients who have not returned for a scheduled review visit recommended by the optometrist. The nature and extent of responsibility for following up tests and results will depend on what is reasonable in all of the circumstances.
Overall, the following factors are important in determining if something is clinically significant and therefore requires follow-up:
• The probability that the patient will be harmed if adequate follow-up does not occur
• The likely seriousness of the harm
• The burden of taking steps to avoid the risk of harm.
A list should be made of patients who fail to attend their appointment or who cancel and fail to reschedule. This list should be reviewed by the optometrist as soon as practicable and a decision made about the follow-up required.
In reviewing the list, the optometrist should assess the clinical significance of each case. Where action is necessary, the clinical significance of the case will determine whether one phone call is adequate, several phone calls at different times of the day are needed, or a letter to the last known address or by registered mail is required.
Where you make a referral to a specialist that may have serious clinical significance, you should also follow up whether the patient attended an appointment with the specialist.
Another good safeguard is to request your practice staff to make the specialist appointment at the time of referral. Clinically significant referrals should also be systematically tracked and removed from the list when a letter or phone call is received from the specialist. This list should also be periodically reviewed for any outstanding referrals.
All attempts at follow-up should be documented in the patient’s medical record. Documentation of phone calls should include the date and time of the call, the name of the person who made the call, any message given and any action taken.
Copies of letters sent should be included in the record, and notations made where letters are sent by registered mail. Missed appointments should also be clearly documented in the records. The appointments system should allow a permanent record of all cancellations and failures to attend.
Proactive systems can help prevent missed appointments. When patients make an appointment they are advised by reception to phone if they won’t be able to attend. Signage or newsletters from the practice can also help to remind patients to phone if they can’t make an appointment.
Patients are asked politely their reason for cancelling an appointment and some practices send SMS reminders the day before an appointment. The practice may want to consider a system of cautions for patients who repeatedly miss appointments.
Frequently, the primary and most time-consuming difficultly experienced by a practitioner is out-of-date patient contact details. You have an obligation under privacy legislation to ensure your records about patients are correct, accurate and up-to-date. It is good practice at each visit to ask the patient to confirm that their contact details are correct and to ensure that any changes are recorded in their file.
In terms of Mrs R’s case and given the seriousness of her symptoms, ensuring she follows your advice is also your responsibility.
1. Optometrists Association Australia. Practice Standards Second Edition, November 2007
Disclaimer: This article is not comprehensive and does not constitute legal advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision-making with regard to the individual circumstances. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is current only at the date initially published.
Avant provides professional indemnity insurance for members of Optometry Australia