Follow-up of Tests, Results and Referrals Policy Template

What's in this template?

This Follow-up of Tests, Results and Referrals Policy gives Australian general practices a complete policy aligned to RACGP Standards 5th edition criterion GP2.2 and the ACSQHC Communicating for Safety Standard. Failure to follow up a test result is the single most common preventable cause of harm in general practice and the most frequent source of medico-legal claims against GPs.

The policy covers 16 sections plus a sign-off block:

1. Purpose: duty of care, GP2.2 requirement, link to Recall and Reminder Policy
2. Scope: pathology, imaging, specialist, allied health, NCSR, My Health Record
3. Definitions: requesting/covering clinician, critical, loop closure, unsolicited result
4. Roles and responsibilities: clinician, coordinator, reception, manager, clinical lead
5. Receipt and routing of results: electronic, paper, phone notifications
6. Clinician review, urgency categorisation: five categories with action timeframes
7. Communicating results to the patient: methods by urgency, SMS minimum disclosure
8. Specialist referrals, closing the loop: referrals, hospital discharge, ED letters
9. Coverage during absence: planned leave, unplanned, clinician departure
10. Documentation: minimum requirements for closing the loop
11. Critical and unexpected results: pathology, imaging, response
12. Patients with additional needs: cultural, language, disability, children, mental health
13. Audit and continuous improvement: daily, weekly, quarterly, annual reviews
14. Training: induction, refresh, locums
15. Related documents
16. Approval and review

Editable placeholder fields

• {{practice_name}}, {{practice_address}}, {{practice_phone}}
• {{clinical_lead}}, {{results_coordinator}}, {{practice_manager}}
• {{clinical_software}}, Best Practice, Medical Director, Helix, ZedMed, etc.
• Sign-off blocks for Clinical Lead, Practice Manager and Results Coordinator

Who needs a Follow-up of Tests, Results and Referrals Policy?

Every Australian general practice and every specialist or allied health practice that orders investigations or makes referrals. RACGP accreditation requires it; insurers expect it; medico-legal review will scrutinise it after any near-miss or claim. The template is suitable for:

• General practices of any size, including corporate and ACCHO networks
• Specialist medical practices that order investigations
• Day procedure clinics that follow up post-procedure histology and imaging
• Allied health practices managing referrals and shared-care correspondence

RACGP requirement at a glance

Criterion GP2.2, Follow-up systems. The RACGP Standards for general practices (5th edition) requires that:

• Patients are advised of the practice's policy on management of results
• Every result received is reviewed by a clinician and an action decided
• Patients requiring follow-up are contacted in a timely way
• Recall is triggered for clinically significant results, missed appointments, and overdue chronic disease care
• A record is kept of every attempt to contact a patient and the outcome
• The system supports closing the loop, not just receipt

This policy delivers the receive-review-decide-document side of GP2.2. The Recall and Reminder System Policy delivers the contact-and-close side. Both are needed for full GP2.2 compliance.

Urgency taxonomy built in to the policy

The category is recorded in the clinical record as a coded action, which links the result to the Recall and Reminder System Policy for closure.

What "closing the loop" actually means

A result is not closed until the clinical record shows:

• It was viewed and reviewed by a named clinician on a date
• A category was assigned
• An action was decided (file, inform, recall, refer, repeat, contact specialist)
• Communication to the patient is logged (method and date) where required
• The outcome of any patient contact is back in the same record

A result "reviewed and filed" with no decision recorded does not close the loop and is at risk in any audit or medico-legal review. This is the single most common gap found by RACGP-accredited surveyors and by medico-legal reviewers.

How to customise this template

1. Download the Word document and replace every {{placeholder}} with your details
2. Confirm clinical software routing: every pathology, imaging and referral letter must reach the right clinician's inbox (Best Practice, Medical Director, Helix, ZedMed and others all support this; the labels differ)
3. Pre-agree critical-result protocols with your pathology and imaging providers: what they phone vs send, who they ask for, who confirms callback
4. Document covering arrangements: every clinician has a nominated covering clinician for leave; the policy refers to a covering arrangements register
5. Brief reception: paper results to the coordinator within one business day; critical phone calls transferred immediately
6. Brief clinicians: coded categorisation on every result, not freeform notes
7. Set the audit cadence: daily inbox audit, weekly ageing report, quarterly random sample, annual incident review
8. Connect to the Recall and Reminder System Policy: this policy produces the trigger; the recall policy governs the contact and closure

Related templates and tools

This policy is one of a pair with the Recall and Reminder System Policy:

• Recall and Reminder System Policy: governs how patients are contacted once a result triages to a recall (the next step after this policy)
• Patient Identification Policy: confirms the right patient against the result
• Clinical Handover Policy: covers coverage during absence and clinician departure
• Open Disclosure Policy: applies when a missed or delayed result has caused harm
• Health Records Management: retention of result documentation
• Practice Information Sheet: communicates the practice's results policy to patients
• Privacy Policy: APP framework that underpins patient contact
• Quality Improvement Policy and Activity Log: receives audit outputs

Frequently asked questions

Is a documented follow-up policy mandatory for RACGP accreditation?

Yes. RACGP criterion GP2.2 explicitly requires it, supported by a procedure that triages every result, documents the action and closes the loop. This is one of the most-cited non-conformities at accreditation when missing or out of date.

How is this different from the Recall and Reminder System Policy?

This policy covers the inbox side, receipt, review, urgency categorisation, decision, documentation. The Recall and Reminder System Policy covers the contact side, how the patient is contacted, how many attempts, what escalation, and how the loop closes. Both are needed for full GP2.2 compliance and they reference each other.

What is "closing the loop"?

Confirming the result has been reviewed by a clinician, an action decided, the patient informed where required, and the outcome documented in the clinical record. A result viewed and filed with no decision recorded does not close the loop. Surveyors and medico-legal reviewers look for this specifically.

How fast must critical results be acted on?

Same business day, by phone, by the requesting or covering clinician. If the lab phones a critical result, the practice responds before that call ends. The policy specifies this in section 11.

What if the requesting clinician is absent?

Every clinician has a nominated covering clinician for planned leave, with auto-routing of the inbox. For unplanned absence, the Practice Manager assigns coverage at start of business. For clinician departure, all inbox items, referrals and recalls are reassigned within one business day and the departed clinician's open work is audited within one week. The policy covers all three scenarios in section 9.

Do we need to inform patients of normal results?

The default policy is yes, the Practice Information Sheet tells patients to expect this. Where a patient prefers no contact for normal results, this is recorded at the time of the request and honoured for normal results only. Abnormal results are always communicated regardless of patient preference, because the duty of care overrides the preference for clinically significant findings.

Can we send results by SMS?

Yes, with two caveats: SMS must not contain clinical detail (only a prompt to contact the practice), and critical results must be communicated by phone or face-to-face, not SMS. The policy provides sample SMS wording.

What about specialist referrals, how do we close the loop on those?

The closing-the-loop trigger is receipt of the specialist's consultation letter, operation report or discharge summary. The Results Coordinator audits referrals over 3 months old without correspondence and prompts the requesting clinician to follow up. Hospital discharge summaries and ED letters are reviewed within one business day on the same urgency taxonomy as results. The policy covers this in section 8.

Will accreditors accept this template?

Yes, when populated. The policy maps directly to RACGP GP2.2 indicators and the ACSQHC Communicating for Safety Standard. Pair it with the Recall and Reminder System Policy for full GP2.2 coverage. The five-category urgency taxonomy, loop-closure documentation, coverage arrangements and audit cadence are what surveyors expect to see.