1 Chapter One - Practice Services - V2

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) ....................................... 1

1.1. Scheduling patient appointments ....................................................................................... 1
1.1.1. Booking an appointment ................................................................................................ 2
1.1.2. Rescheduling an appointment – changed by a patient .................................................. 2
1.1.3. Rescheduling an appointment – changed by the practice .............................................. 2
1.1.4. Recording missed appointments ................................................................................... 3
1.1.5. Cancelled and missed appointment fees ....................................................................... 4
1.2. Triage ................................................................................................................................ 5
1.3. Emergency telephone call with doctor present ................................................................... 6
1.4. Emergency telephone call and no doctor present .............................................................. 7
1.5. Emergency patient presents to reception with doctor present ............................................ 7
1.6. Emergency patient presents to reception and no doctor present ........................................ 8
1.7. Patient discomfort in waiting room ..................................................................................... 9
1.8. Dialling emergency ‘000’ .................................................................................................... 9
1.9. Subsequent action following an emergency or exceptional situation ................................ 10
1.10. Referring important information to the general practitioner ............................................... 10
1.11. Length of consultations .................................................................................................... 11
1.12. Patients with special needs .............................................................................................. 11
1.13. Practice closures ............................................................................................................. 12
1.14. Visitors ............................................................................................................................. 12
2. TELEPHONE AND OTHER COMMUNICATIONS (CRITERION 1.1.2) .............................. 13
2.1. Telephone communication ............................................................................................... 13
2.1.1. Telephone techniques ................................................................................................. 14
2.1.2. Answering incoming calls ............................................................................................ 15
2.1.3. Placing callers on hold ................................................................................................ 15
2.1.4. New patients ............................................................................................................... 16
2.1.5. Telephone requests for referrals.................................................................................. 16
2.1.6. Telephone requests for repeat prescriptions ............................................................... 17
2.1.7. Telephone requests for results .................................................................................... 18
2.1.8. Taking messages ........................................................................................................ 19
2.1.9. Clinical messages ....................................................................................................... 20
2.1.10. Outgoing calls ............................................................................................................. 21
2.1.11. Handling difficult patients............................................................................................. 22
2.2. Electronic communication ................................................................................................ 23
2.3. Telephone and electronic equipment ............................................................................... 23
2.3.1. Telephone functions .................................................................................................... 23
2.3.2. Telephone problems.................................................................................................... 24
2.3.3. Email ........................................................................................................................... 24
2.4. Fees for telephone and electronic communications.......................................................... 24
3. HOME AND OTHER VISITS (CRITERION 1.1.3) .............................................................. 25
3.1. Providing safe and reasonable care ................................................................................. 25
3.2. Access to alternative sources of care ............................................................................... 25
3.1. Who can perform home or other visits.............................................................................. 26
3.2. Safety of health professionals .......................................................................................... 27
4. CARE OUTSIDE NORMAL OPENING HOURS (CRITERION 1.1.4) ................................. 28
4.1. Options for care outside normal opening hours ................................................................ 28
4.2. Formal after-hours agreements ........................................................................................ 29
4.3. Follow up of tests taken during after-hours care............................................................... 29
4.4. Who can provide after-hours care for the practice ............................................................ 30
4.5. Communicating our after-hours arrangements ................................................................. 30
5. PRACTICE INFORMATION (CRITERION 1.2.1) ............................................................... 31
5.1. Practice information sheet................................................................................................ 31
5.2. Advertising practice information ....................................................................................... 31
5.3. Practice website............................................................................................................... 32
5.4. Practice services .............................................................................................................. 32
5.5. Practice hours .................................................................................................................. 32
6. INFORMED PATIENT DECISIONS (CRITERION 1.2.2) .................................................... 33
6.1. Providing appropriate and sufficient information to patients ............................................. 33
6.2. Informing patients of potential treatment costs ................................................................. 33
6.3. Patient-doctor collaboration ............................................................................................. 34
7. INTERPRETER AND COMMUNICATION SERVICES (CRITERION 1.2.3) ....................... 35
7.1. Patients of foreign background and ethnicity .................................................................... 35
7.1.1. Translating services .................................................................................................... 36
7.1.2. Using friends and relatives as interpreters ................................................................... 37
8. COSTS ASSOCIATED WITH CARE (CRITERION 1.2.4) .................................................. 38
8.1. Fees for services and billing practices ............................................................................. 38
8.1.1. Private billing ............................................................................................................... 38
8.1.2. Bulk billing ................................................................................................................... 39
8.1.3. Department of Veterans Affairs ................................................................................... 40
8.1.4. Workers compensation ................................................................................................ 41
8.1.5. Medical examinations not covered by Medicare .......................................................... 42
8.1.6. Pre-employment medicals ........................................................................................... 42
8.2. Costs of other health services .......................................................................................... 43
9. HEALTH PROMOTION AND PREVENTATIVE CARE (CRITERION 1.3.1) ....................... 44
9.1. Health promotion activities ............................................................................................... 44
9.2. Preventative care ............................................................................................................. 45
9.2.1. Vaccination and occupational health clinics ................................................................. 45
9.2.2. Mole scan unit ............................................................................................................. 45
9.2.3. Asthma awareness ...................................................................................................... 45
9.2.4. Seasonal ‘flu clinics ..................................................................................................... 46
9.3. Health risk assessments .................................................................................................. 47
9.4. Managing patient information to support preventative care .............................................. 47
9.5. Clinical resources for the practice – preventative health .................................................. 48
10. CONSISTENT EVIDENCE BASED PRACTICE (CRITERION 1.4.1) ................................. 49
10.1. Clinical practice guidelines ............................................................................................... 49
10.2. Clinical resources for the practice – evidence based practice .......................................... 50
10.3. Patient identification – prior to surgery ............................................................................. 51
10.4. Health inequalities ........................................................................................................... 52
10.5. Consistent communication ............................................................................................... 53
11. CLINICAL AUTONOMY FOR GENERAL PRACTITIONERS (CRITERION 1.4.2) .............. 54
11.1. Clinical autonomy within evidence based care ................................................................. 54
11.2. Professional and ethical obligations ................................................................................. 54
12. CONTINUITY OF COMPREHENSIVE CARE AND THE THERAPEUTIC RELATIONSHIP
(CRITERION 1.5.1) ................................................................................................................... 55
12.1. Provider continuity and patient outcomes......................................................................... 55
12.2. The doctor patient relationship ......................................................................................... 56
12.3. Courtesy notifications....................................................................................................... 56
12.4. Supporting preferred relationships ................................................................................... 57
13. CLINICAL HANDOVER (CRITERION 1.5.2) ...................................................................... 58
13.1. Defining clinical handover ................................................................................................ 58
13.2. Clinical handover actions ................................................................................................. 59
13.3. Transfer of patient health information to another practice ................................................ 60
13.4. Transfer of patient health information – from another practice ......................................... 61
13.5. Errors in clinical handover ................................................................................................ 61
14. FOLLOW UP OF TESTS AND RESULTS (CRITERION 1.5.3) .......................................... 62
14.1. Definitions ........................................................................................................................ 62
14.2. Essential follow up systems ............................................................................................. 63
14.3. Receiving incoming results and reports............................................................................ 64
14.4. Conducting a review of follow up systems ........................................................................ 65
14.1.1. The general practitioner and the reminder system ....................................................... 66
14.1.2. Practice staff and the reminder system........................................................................ 66
14.1.3. The general practitioner and the recall system ............................................................ 67
14.1.4. Practice staff and the recall system ............................................................................. 67
14.5. Issuing recalls .................................................................................................................. 68
14.6. Reminders ....................................................................................................................... 69
14.7. Errors in follow-up ............................................................................................................ 70
14.8. Sending letters to patients................................................................................................ 70
15. ENGAGING WITH OTHER SERVICES (CRITERION 1.6.1).............................................. 71
15.1. Patient resources ............................................................................................................. 71
15.2. Staff resources................................................................................................................. 71
15.3. Location of resources....................................................................................................... 72
16. REFERRAL DOCUMENTS (CRITERION 1.6.2) ................................................................ 73
16.1. Unique patient identifiers ................................................................................................. 73
16.2. Sufficient information ....................................................................................................... 74
16.3. Disclosure of patient information ...................................................................................... 74
16.4. Telephone referrals .......................................................................................................... 74
17. PATIENT HEALTH RECORDS (CRITERION 1.7.1) .......................................................... 75
17.1. Dedicated patient health records...................................................................................... 75
17.1.1. Creating a new medical record .................................................................................... 76
17.1.2. Retention of records and archiving .............................................................................. 76
17.1.3. Destruction of medical records .................................................................................... 77
17.1.4. Collecting information from patients ............................................................................ 77
17.1.5. Recording cultural background .................................................................................... 78
17.1.6. Recording Aboriginal and Torres Strait Islander status ................................................ 78
18. HEALTH SUMMARIES (CRITERION 1.7.2)....................................................................... 79
18.1. Health summaries for safe and high quality care .............................................................. 79
18.2. Coding ............................................................................................................................. 79
19. CONSULTATION NOTES (CRITERION 1.7.3) .................................................................. 80
19.1. 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 appointments

Patients 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 appointments

Select 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


1.1.5. Cancelled and missed appointment fees

Our 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. Triage
This 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

 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

1.1. Emergency telephone call with doctor present

Under 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.
 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.
 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.
 Category 6
 Make an appointment within 24 hours and advise the patient to call back if symptoms
worsen.
 Inform nurse or doctor.

1.2. Emergency telephone call and no doctor present

Category 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 present

Category 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 present

Category 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 room

Patients 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:

1.7. Subsequent action following an emergency or exceptional situation

It 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 practitioner

Our 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 consultations

Each 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 needs

Our 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 closures

Should 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 13 - Clinical handover
1.12. Visitors
Patients 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 communication

Our 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 techniques

1. 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 calls

1. 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 hold

1. 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 patients

New 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 referrals

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 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 prescriptions

For 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.
<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>
practice that all patients are required to make an appointment with a doctor for repeat
prescriptions. There are no exceptions.
<Option 3>
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 results

Patients 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 messages

All 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 messages

If 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 calls

To 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.

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 patients

At 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 communication

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 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 equipment

The 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 functions

All 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 problems

The 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. Email
Patient 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 communications

Our 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 care

Our 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 care

If 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 visits

Our 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.

 Safety, quality improvement and education, Chapter 5 - Qualifications of general
practitioners

1.18. Safety of health professionals

This 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 hours

<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

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 care

Our 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 practice

Our 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.

 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 sheet

Our 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 information

All 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 website

<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 services

In addition to medical consultations, this practice offers the following services:
1.14. Practice hours

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


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 patients

Our 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 costs

Complaints 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 collaboration

Our 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

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 services

This 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 interpreters

<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 practices

Our 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 billing

<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 billing

When 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 compensation

Workers 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 Medicare

Several 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 medicals

Many 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 services

Our 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 activities

Our 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/.

1.22. Preventative care

Our 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 clinics

Our 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 awareness

Our 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.

1.1.30. Seasonal ‘flu clinics

Our 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

1.23. Health risk assessments

Our 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 care

Members 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.

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 guidelines

Our 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

1.28. Patient identification – prior to surgery

Our 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

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

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 care

Our 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 obligations

All 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 outcomes

The 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:

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 relationship

Our 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 notifications

Where 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 relationships

Our 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 handover

The 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 actions

The 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

1.39. Transfer of patient health information to another practice

Transfer 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 practice

At 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 handover

Our 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. Definitions
The 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 systems

This 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 reports

All 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 systems

A 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 system

Establish 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 system

Establish 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 system

Establish 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 system

Establish 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 recalls

On 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. Reminders
Reminders 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 patients

All 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 resources

This 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 resources

This 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 resources

Health 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 identifiers

At 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 information

Our 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 information

Our 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 referrals

Telephone 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 records

This 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 record

<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 archiving

This 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 records

Records 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 patients

All 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 background

Our 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 status

All 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/

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 care

A 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

1 Chapter One - Practice Services - V2

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The following template policies and procedures

are based on the requirements of the

1. SCHEDULING CARE IN OPENING HOURS (CRITERION 1.1.1) ....................................... 1

1. SCHEDULING CARE IN OPENING HOURS (CRITERION 1.1.1)

Our practice provides timely care and advice to our patients.

1.1. Scheduling patient appointments

For more information please refer to policies:

 Practice services, Chapter 1.2 - Triage

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.

1.1.2. Rescheduling an appointment – changed by a patient

1.1.3. Rescheduling an appointment – changed by the practice

Information contained in this manual is current at February 2015

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

1.1.4. Recording missed appointments

For more information see:

 Practice services, Chapter 1.1.5 - Cancelled and missed appointment fees

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 3

1.1.5. Cancelled and missed appointment fees

The non-attendance fee is not refundable from Medicare.

Information about this policy is found on public display:

 In the patient waiting room

For more information see:

 Practice services, Chapter 1.2 – Triage

Information contained in this manual is current at February 2015

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

For more information see:

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 5

1.1. Emergency telephone call with doctor present

Information contained in this manual is current at February 2015

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

1.2. Emergency telephone call and no doctor present

1.3. Emergency patient presents to reception with doctor present

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 7

1.4. Emergency patient presents to reception and no doctor present

1. If a Category 1 or 2, implement the DRABC (Danger Response Airway Breathing Circulation)

Information contained in this manual is current at February 2015

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

1.5. Patient discomfort in waiting room

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

1.6. Dialling emergency ‘000’

For more information, see:

 Practice services, Chapter 1.2 - Triage

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 9

1.7. Subsequent action following an emergency or exceptional situation

Following an emergency or exceptional situation:

1.8. Referring important information to the general practitioner

Please refer to:

FRONT DESK TRIAGE POSTER

Information contained in this manual is current at February 2015

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

1.9. Length of consultations

Our standard appointment time is <standard appointment time>.

1.10. Patients with special needs

For more information see policies on:

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 11