Seeing unfamiliar patients on home visits from an unfamiliar practice in an unfamiliar area. What could go wrong? Dr Rachel Birch from the MPS gives some helpful advice.
Dr S was working at a semi-rural practice for the morning. It was a busy Monday and there were a lot of home visit requests that day. She was asked to visit an elderly gentleman with sickness and diarrhoea before going on to her afternoon session at another practice.
She was given directions by reception staff and set off. It was February and on her way it started to snow. After ten minutes and becoming increasingly more rural, she found herself on a single track road, she realised she had become lost. She tried to call the practice but realised she had no mobile phone signal.
Dr S had no choice but to return to the practice and obtain further directions. She managed to find the patient’s house on the second attempt. The patient was feeling nauseated and could not keep anything down without vomiting. She recommended admission to hospital but he refused to go. She administered an IM antiemetic, advised oral fluids and told the patient that he would need a further review at the end of the day. By this stage it was ten to two and she was due to start consulting at the second practice at 2pm.
She did not have time to go back to the practice to write up her home visit and went directly to the second practice. She did call the practice and spoke to the duty doctor for the afternoon who agreed to visit the patient again at the end of the afternoon. She emailed the GP with details of her consultation and agreed to return to the practice the following day to write up the consultation in the medical record.
Although the situation was not ideal, Dr S did her best in this challenging situation, which highlights some of the pitfalls of home visits that locum GPs may face.
Medical records and home visits
The GMC states that doctors “should make records at the same time as the events you are recording or as soon as possible afterwards”. This can present a practical problem for locum doctors, who may be doing a session at a different practice in the afternoon.
Wherever possible, locums should return to the practice after their visit to document the consultation in the clinical record, including any medication administered or prescription issued.
If the recording of the visit is delayed, this presents a risk to patients, as if further review is required, there will be no record of the previous assessment. In the above situation Dr S had to make a compromise, and arrange to email details to the duty doctor, but did make arrangements to write up the visit the following day. Doctors should not rely on the use of transcripts or asking reception staff to enter details of home visits.
Triage of home visit requests
In many practices, doctors undertake telephone consultations first with any patient requesting a home visit. Reasons include assessing the need for a home visit, considering the urgency of the situation, ensuring that a doctor is the most appropriate person to visit and providing telephone advice.
There is the risk that if the request is triaged by a different doctor, who then asks the locum doctor to visit, the subtleties of the circumstance may be missed. There may be reasons for seemingly trivial visit requests. For example, they may not know that the single mother who asks them to come and look at her five year old’s eczema actually lost his twin sister to meningitis last year.
Similarly, if locum GPs are undertaking telephone triage of visit requests, they may wish to speak to one of the regular doctors if a visit request seems excessive, as they can provide helpful background social and medical information. Locums should clarify the home visit procedures within the practice and patients’ usual expectations. Are the telephone calls used simply to gauge the urgency? Does everyone who requests a visit usually get one? Are there some patients who you should have a lower threshold for visiting? Perceived failure to visit is a common source of complaint, so it is important for locum GPs to establish how practices manage home visit requests.
Lack of local knowledge
Anyone who has worked in general practice will know that postcodes are not enough for finding patients’ houses. Locum doctors should ask practices to supply them with maps of the area. If embarking on a visit, speak to reception staff too. They are usually local and can best describe how to get to a patient’s home. Bizarre house numbering can confuse even the most experienced locum, as can local road closures.
A knowledge of and contact details for local services is important too. Locum doctors should be provided with access to the practice's Spip, which details contact details for district nurses, health visitors, ambulance control and hospitals.
Locum doctors may find themselves on a visit, with only the patient summary sheet for information. Consider taking five minutes before the visit to read through the record and talk to the regular doctors. They may know the patient well, and taking time to do this may save you time on the actual visit as well as providing relevant clinical information.
In the ideal world it is also helpful to meet with the regular GPS to divide up the home visits and decide who is the most appropriate person to visit. For example, a bereavement visit would be a less suitable choice for the locum who has never met the patient before. On return from a visit, do not hesitate to discuss the patient with their usual doctor, if you have any doubts or concerns.
As the above case illustrates, locum doctors may be working in two different practices in the same day. It is important to plan sessions to minimise any stress and physical tiredness from working in such a way. Locums should highlight to practices, in advance, what time they will need to leave, and ensure that adequate time is provided to them for undertaking home visits and recording them afterwards.
Locum GP work can be very rewarding and, by considering and reducing any potential pitfalls in advance, many find home visits an enjoyable part of their role.
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