What's in this template?
This Recall and Reminder System Policy gives Australian general practices a complete policy aligned to RACGP Standards 5th edition criterion GP2.2 and the Privacy Act 1988 / APP 7. A documented recall and reminder system is one of the most frequently scrutinised areas at accreditation, and missed or late follow-up is one of the most common sources of medico-legal claims against GPs.
The policy covers 15 sections plus a sign-off block:
- Purpose: duty of care, GP2.2 requirement
- Definitions: recall vs reminder vs opt-out
- Scope: what we always recall and what we routinely remind for
- Roles and responsibilities: clinician, coordinator, reception, manager, clinical lead
- Recall workflow: receipt of result through to closure
- Urgency and contact timeframes: critical, urgent, routine, reminder
- Contact methods: SMS, phone, letter, email, portal, in-person
- Privacy and APP 7 considerations: direct care vs direct marketing
- National screening programs: NCSR, AIR, hospital shared care
- Patients with additional needs: cultural, language, disability, regional, vulnerable
- Failure to respond: exhausted attempts and documented decision-making
- Audit and continuous improvement: monthly, quarterly, annual reviews
- Training: induction, refresh, locums
- Related documents
- Approval and review
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{{practice_name}},{{practice_address}},{{practice_phone}}{{clinical_lead}},{{recall_coordinator}},{{practice_manager}}{{clinical_software}}, Best Practice, Medical Director, Helix, MedicalDirector Clinical, ZedMed, etc.- Sign-off blocks for Clinical Lead, Practice Manager and Coordinator
Who needs a Recall and Reminder System Policy?
Every Australian general practice. RACGP accreditation will not be issued without a documented recall and reminder system supported by a policy and a register. The template is suitable for:
- General practices of any size, solo, group, corporate
- Aboriginal Community Controlled Health Services (ACCHOs): with cultural-safety customisations
- Specialist practices that routinely follow up results or procedures
- Day procedure clinics that recall post-procedure
- Allied health practices: particularly where they manage a follow-up workflow
RACGP requirement at a glance
Criterion GP2.2, Follow-up systems. The RACGP Standards for general practices (5th edition) requires that the practice has a system that allows:
- Patients to be advised of the practice's policy on the management of pathology, imaging and other test results
- Clinicians to review every result received and decide what action is required
- Patients who require follow-up to be contacted in a timely way
- Recall of patients for clinically significant results, missed appointments, and overdue management of chronic disease
- A record kept of attempts to contact patients and the outcome
The policy is one of the most commonly cited non-conformities at RACGP accreditation when missing, out of date, or not actually followed in practice.
Why the recall vs reminder distinction matters
| Term | Meaning | Practical effect |
|---|---|---|
| Recall | Clinically necessary contact triggered by a specific result, treatment or risk. Failure to act may cause harm. | Active follow-up to closure. Multiple attempts and escalation required. Cannot be opted out of (only channel can be changed). |
| Reminder | Prompt to attend for routine, preventive or planned care. | One reminder, optional repeat. Patient may opt out entirely. |
This distinction maps directly to the Privacy Act APP 7 (direct marketing) rules, recalls of an existing clinical episode are direct care and are exempt; broader health-promotion reminders are direct marketing and require opt-out.
Urgency tiers built in to the policy
| Urgency | First contact within | Escalation |
|---|---|---|
| Critical (e.g. dangerously abnormal result, suspected malignancy) | Same business day, by phone | Repeat 24h, registered letter, next of kin |
| Urgent (significant abnormal result, infant immunisation overdue) | Within 2 business days | Second contact 7 days, letter 14 days |
| Routine recall (stable chronic disease, non-urgent abnormal) | Within 7 business days | Second contact 14 days, letter 30 days |
| Reminder (annual flu, screening interval, care plan review) | Pre-scheduled | One repeat, no further action if no response |
Practices can tune the timeframes to their clinical mix without changing the policy structure.
How to customise this template
- Download the Word document and replace every
{{placeholder}}with your details - Settle the clinical scope: minimum: results requiring action, immunisation, cervical and bowel screening, chronic disease cycle of care, procedures requiring follow-up
- Confirm the clinical software is set up: coded reasons, recall register, escalation triggers (Best Practice, Medical Director, Helix all support this; the labels differ)
- Choose contact methods and templates: write the actual SMS and letter wording the policy refers to; avoid clinical detail in SMS
- Brief clinicians and reception: clinicians own the clinical decision to recall; reception owns the practical follow-through
- Set the audit cadence: monthly KPIs, quarterly sample audit, annual systemic review by the clinical lead
- Connect to the patient-facing material: the Practice Information Sheet and Privacy Policy must both reference the recall and reminder system and how patients are contacted
Related templates and tools
The Recall and Reminder Policy sits at the centre of GP2.2 compliance:
- Follow-up of Tests, Results and Referrals Policy: the sibling document covering result receipt, clinician review, triage and acknowledgement (the workflow the recall depends on)
- Patient Identification Policy: confirms the right patient is being contacted
- Health Records Management: retention of recall attempts and closure records
- Privacy Policy and Patient Data Collection Notice: patient-facing notification that the practice runs a recall system
- Direct Marketing and Patient Communications Privacy Policy: covers health-promotion reminders (APP 7)
- Quality Improvement Policy and Activity Log: recall audit outcomes feed the QI cycle
- Practice Information Sheet: front-of-house communication of how recall works
Frequently asked questions
Is a documented recall and reminder system mandatory for RACGP accreditation?
Yes. RACGP criterion GP2.2 explicitly requires a documented system supported by a register and a procedure for follow-up. Missing or non-current documentation is one of the most common non-conformities cited at accreditation.
Can patients opt out of recalls?
Patients may opt out of routine reminders but cannot opt out of clinically necessary recalls. They may decline the recall once contacted, but the practice's duty to make a reasonable attempt to contact them remains. The refusal is documented in the clinical record.
Does APP 7 (direct marketing) apply to recalls?
No, when the recall is direct follow-up of an existing clinical episode. Yes, when sending broader health-promotion content (e.g. promoting a new flu clinic to all patients). The policy distinguishes both pathways. The Direct Marketing and Patient Communications Privacy Policy covers the second case in detail.
What contact methods are acceptable?
SMS, phone, letter and (with prior written consent) email. SMS should not contain clinical detail. Phone is required for urgent and critical recalls. Letter (registered) is the standard third-attempt escalation. The policy includes a sample minimal SMS.
How long are recall records retained?
Recall records are retained as part of the clinical record per the Health Records Management policy, minimum 7 years for adults, 7 years from age of majority for minors, longer in some states (e.g. Victorian Health Records Act). Most clinical software automatically retains the recall register.
What if we cannot contact a patient after multiple attempts?
The treating clinician reviews the file and decides on next steps, additional channels, contact via next of kin (if consented at registration), notifying another treating clinician, or in extreme cases referral to a statutory authority where there is critical risk. The decision and rationale are documented. The policy describes this in section 11.
How does this work with the National Cancer Screening Register and AIR?
The NCSR sends most invitations directly to patients for cervical and bowel screening, the practice does not duplicate. The practice recalls when a screening result requires follow-up (e.g. positive FOBT needing colonoscopy). The Australian Immunisation Register is cross-referenced to identify missed doses, and recalls are issued accordingly. The policy spells out the coordination boundary in section 9.
Will accreditors accept this template?
Yes, when populated. The policy maps directly to RACGP GP2.2 indicators. The structure, register, urgency tiers, escalation, audit, is what RACGP-accredited surveyors expect to see. Pair it with the Follow-up of Tests, Results and Referrals Policy for full GP2.2 coverage.