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Managing Patient Follow-up

Acknowledgement of IUIH

We would like to thank the Institute of Urban Indigenous Health (Queensland) for sharing their clinic workflows which are the framework for these workflow pages.
These workflows are intended as a guide only, to show how you might use MMEx to efficiently manage patients and workload.

Patient Follow-up

Patient follow up in primary health care can be organised by:

  1. Opportunistic follow up
  2. One off recalls
  3. Long term/recurring recalls

MMEx is set up to help staff manage all types of patient recall.

Opportunistic follow up

The most resource efficient way to provide timely care and follow up is to complete tasks when the patient is attending for another reason. It recognises that the patient is already present and quite often willing to participate in health care/promotion beyond what they had originally attended the clinic for. It adds value to every patient-staff contact.

For effective opportunistic care, health services must

  • know what follow up/monitoring the patient is due for
  • be organised to offer this as the patient attends their service

Using MMEx, staff are prompted to provide opportunistic care through the patient’s ‘To Do List’. The To Do List button is found on the Patient's Summary screen. It is coloured red when there are outstanding tasks or activities to be done.

Within the To Do List:

  • The Tasks tab lists the one off / short term tasks – these tasks are created by an MMEx user
  • The Care Plan Activities tab lists the long term surveillance / monitoring for lifetime surveillance or known health problems (which are currently due / overdue) – these activities are generated by the Care Plans which have been applied to the patient.

Completing a Task

Right-Click will reveal a menu with a range of options to assist you to manage the task.

You can also track your attempts to contact a patient about this task.

Additional Information about the Tasks Feature can be found here

Completing a Care Plan Activity

As patients are seen, staff decide what follow up can be included in the current consult (within their scope of practice) and may decide with the patient to schedule a further appointment to complete any outstanding tasks and reviews if necessary.

Expand the Care Plan Activity and enter the relevant information in the available fields. You may add additional comments to detail where, when or by whom the task was completed if was done elsewhere, or on a different date.

Click Save Selected Activities

And the task will be removed from the To Do List. You may complete multiple tasks and save them all with one click.

When patients don’t attend within the time due to meet all their screening / follow up needs opportunistically (or when resources to maximise opportunistic care are insufficient / less organised), the health service has a duty of care to organise the recall of patients who are due or have become overdue for their essential follow up care.


Organising recalls can be done by searching Tasks and Care Plan Activities

One-off recalls

One off recalls are best managed as Tasks in MMEx.

Tasks are set up to prompt separately to care plans to ensure they stand out and not be mixed in with other routine care plan prompts. (E.g. a high BP is observed in a patient with no previous history of hypertension. Their BP needs to be repeated before a diagnosis and management commenced. Adding the follow up BP review as a Task means it can be searched for easily – without being lost amongst care plan prompts for BP checks.)

You can add a new task using the New Task button. Additional Information about the Tasks Feature can be found here

It is recommended that Services designate a staff member(s) to oversee the MMEx Task list. Responsibilities would include:

  • A daily search for tasks that are overdue and due today and provide direction/support to staff to perform them
  • Ensure priority is given to the most urgent Tasks and that staff update each Task when complete (or attempt to perform).
  • Archive each Task once they are complete
  • Services should agree on the number of attempts staff should make to complete. Once this is reached, staff can send the requester a message to decide whether follow up can be abandoned (and the Task can be archived without completion) or whether the service should keep trying.
  • Encourage discussion of any issues regarding managing Tasks with individual staff and at staff meetings.

Long term (Ongoing) recalls

Long term recalls are best managed through MMEx Care Plans

The reasons these need to be organised separately to Tasks include:

  • The MMEx Lifetime Surveillance Care Plan sets the foundation to manage long term screening, immunisation and health promotion throughout life and are based on the patient’s age, gender and ethnicity.
  • As significant health risks/problems which require long term monitoring are diagnosed, additional care plans can be assigned and together these form an integrated schedule and standing order of care for the patient.
  • Criteria for diagnosis must be met before an Care Plan is assigned, so while these criteria is still being established, Tasks should be used to ensure these patients are followed up.
  • Assigning a Care Plan applies a schedule of evidence based care which updates the Lifetime Surveillance Care Plan schedule. This integrated schedule is reportable – it informs reports on disease prevalence, coverage of care provision and identifies which patients are overdue essential care (or becoming due timely care in the near future).

Additional information about Care Plans is available here.

It is recommended that Health Services designate a staff member(s) who are responsible for regularly pulling recall information from MMEx and organising the health team to perform the work and update MMEx information.

Bulk Mailouts - recall letters for Care Plan Activities

Reports / Patient Reporting provides an option to generate a Bulk Action of Recall letters to be sent to Patients for specific Care Plan Activities

Your service may create templates for frequent “recall” activities such as:

  • 715 Recall Letter
  • Childhood Immunisation Recall
  • GPMP Recall
  • GPMP Review Recall
  • Pap Smear Recall
  • Fluvax Recall

These letters are set up in a Word doc and uploaded to Reminder Mailing. Selecting appropriate letters will generate a multipage Word doc with an individual patient letter per page. These letters can be mailed, or given to a worker to hand deliver to a patient.

Open the Reports page and select Patient Reporting Select the relevant Demographic parameters For Example:

From the Care Plan Activities tab select the relevant care plan activity for which you want to generate recall letters.
For Example:

After selecting ALL parameters for a care plan activities recall report, run the report by clicking Search

When you have a list of names select Generate Letters from the bulk action drop down box Click on Bulk Action This opens a new box

Click on Use next to the Required Template Click Use Selected Template This will generate a Word doc with multiple pages. This will open in Downloads as a Reminder Letters.doc (usually on bottom left of screen). Clicking on the download will open Word. Click Enable Editing to open.

When the Word document has opened, the bottom left will indicate how many pages are generated

When word doc is generated check that there are no TEST patients there, you can delete them by highlighting and deleting just the relevant pages – or by selecting only the relevant pages to print.

The word doc will generate a letter per page for each patient and the relevant recall.

The following is a sample RECALL letter. Note that all templates created autofill with the date and patients details. However the sender (eg Clinic Nurse or Practice Manager) is hard typed into the initial template.

manual/workflows_patientfollowup.txt · Last modified: 2019/06/30 23:41 by sarahb