Improving Patient Care

Using a Tracking Book for Unresolved Issues

This simple strategy will help you and your staff reduce errors and provide better follow-up care.

Peter Schludermann, MD

Tool inside

Several years ago, I saw a healthy 29-year-old man who "just wanted some moles checked." On one plantar surface, he had a pigmented atypical lesion, which I advised him to have removed. An excisional biopsy was performed. The pathology report I received about six days later said, "Compound melanocytic neoplasm. Final report pending consultation." At the patient's suture removal, I told him the final report was likely OK and coming soon. After the visit, I told my nurse to make a note regarding the expected final report in our tracking book for unresolved issues.

My nurse and I then went on with our work of seeing other patients, quickly forgetting about the pending second report. But our tracking book didn't. At the end of the month, when my nurse did her monthly review of the tracking book entries, we were reminded that we still had not received the final report and called the pathology lab. The pathology staff, surprised we had not received the final report, promptly faxed it to us. Dated four weeks earlier, the second pathology report read, "Melanoma, lateral right foot, measuring approximately 0.70 mm in thickness extends close to the surgical margin; excision to ensure its complete removal would be judicious."

As every physician knows, a melanoma is a life-threatening cancer that is best removed early and completely. Without our tracking book, we would not have received the second report or remembered to ask for it, and our patient would not have received timely follow-up care.

Develop your own tracking book

A simple tracking book can be used to follow up on any unresolved issues of concern to the physician. For example, you might want to check that the results of a shave biopsy have been received, that the referral of a patient with a worrisome breast lump has been completed, that an X-ray or CT result has been received, that an untreated noncompliant patient with severe hypertension has kept his follow-up appointment, that a patient's post-vasectomy semen specimen has been taken, and so on. You and your staff can decide which issues require tracking. When they arise, simply record them as a new entry in the tracking book. Often a one-sentence entry is sufficient. (See the sample tracking book entries.)

When using a tracking book for unresolved issues, assign one staff member the task of checking the book on a regular basis (such as the first day of every month), following up on each issue (or delegating follow-up to the appropriate staff person) and documenting what actions were taken (e.g., "Phoned the pathology lab and requested the report" or "Sent a reminder letter to the patient"). Continue following up on each entry until it has been resolved satisfactorily and marked "completed" in the tracking book.

A SAMPLE TRACKING BOOK

This tracking book can be downloaded as a PDF. Shown below is a page from a tracking book used to follow up on patients" unresolved issues. When an issue arises, the physician asks the nurse to record it in the tracking book, noting the date and providing a brief but descriptive entry. On the first of the month, the nurse consults the tracking book and begins follow-up on each item requiring action. Follow-up dates and actions are recorded, and entries are marked completed only after the issue is satisfactorily resolved. Follow-up actions should also be noted in the patient record, particularly if the issue is not resolved (e.g., a patient does not return for follow-up care despite your efforts). Entry date and description Follow-up date and actions Initials Completed 2/17/04: Mary Jones" X-ray is pending. 3/1/04: Called diagnostic imaging; they will send it today. CK 2/17/04: Check that Joe Smith has kept his diabetes checkup scheduled for mid-April.     2/20/04: Shave biopsy results are expected for John Baker. 3/1/04: Results were received on 2/24/04 and signed off by Dr. Adams. CK 2/23/04: Check that Dr. White sends his consult report for Susan Richards. 3/1/04: Called Dr. White"s office; they will fax the report today. CK 2/24/04: Mark Allen should drop off his post-vasectomy semen specimen by 3/24; he may need a reminder letter.

Small strategy, big results

Although the goal for every practice should be to track 100 percent of results and referrals, most offices do not have such a secure system in place. A tracking book for unresolved issues is a simple strategy that any office can implement today. It helps practices close the loop on unresolved issues and relieves physicians and staff from the impossible task of trying to remember the details of each patient visit. Most importantly, it helps practices provide timely and appropriate care to their patients.

Dr. Schludermann is a family physician in Portland, Ore. Conflicts of interest: none reported.

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