๐Ÿ—’ Continuity of care – Keeping patients and practitioners safe

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Continuity of care is a pivotal aspect of healthcare and a core element of high-performing primary healthcare systems. It refers to the comprehensive and well-integrated management of a patient either by a single healthcare professional or a group of practitioners working in a collaborative manner[1]. Despite the well-known effects of continuity of care in improving patient outcomes[2], reducing mortality rates[3], use of anti-psychotics in aged care[4] and the use of emergency departments and preventable hospital admissions[5], there is often lack of understanding of the potential medico-legal issues that may arise out of fragmentation of care in different clinical settings.

Barriers and facilitators of continuity of care

There are several similar barriers and facilitators that affect patient transitions and engagement in care after discharge from hospital or while receiving primary healthcare where a significant level of coordination between care settings is needed.


  • Poor communication
  • Insufficient cooperation and coordination
  • Blurred professional role boundaries
  • Lack of training for role development
  • Location and lack of available resources
  • Poor planning
  • Poor patients’ knowledge


  • Team leadership
  • Decision making
  • Face-to-face communication between teams
  • Professional skills of clinicians
  • Personal characteristics of clinicians (personable, approachable, open, and honest)

Regulatory and professional considerations

The Medical Board of Australia’s Good Practice Guide[6] states:

3.1.1 Assessing the patient, taking into account the history, the patient’s views, and an appropriate physical examination.

3.1.2 Formulating and implementing a suitable management plan

3.1.3 Facilitating coordination and continuity of care.

10.5.4 Ensuring that the records are:

  • Sufficient to facilitate continuity of patient care:
  • Ensure all entries are accurate and up to date
  • Include all relevant details of clinical history
  • Record all clinical findings, investigations and diagnosis
  • Record any information (brochures, written explanations) given to patients to assist them in understanding their conditions, treatment and/or providing informed consent
  • Any prescription, medications and referrals made should be recorded
  • All relevant management and triage of information.

Similar statements in Dental Board of Conduct:

2.1 c) Facilitating coordination and continuity of care

8.4 d) Ensuring that records are sufficient to facilitate continuity of care

Professional considerations

RACGP Standard 7.1: Content of patient health records

  • Complete patient health records improve patient safety & clinical decision
  • making.
  • Consultation notes & patient health records are CRITICAL to manage legal risks.
  • Failure to follow up matters that patients have previously raised, pose significant legal
  • risk to practices and practitioners.

RACGP Standard 2.1 Continuous and comprehensive care

  • Continuity of care lowers health costs & increases patient satisfaction.
  • Supports the provision of quality patient care.
  • Reduces the use of emergency departments and preventable hospital admissions.

RACGP Standard 2.2 Follow-up systems

  • Test results affect the choices made by patients, GPs, and other clinicians about the
  • patient’s care.
  • Clinically significant results need to be communicated quickly and appropriately.
  • Best practice to inform patients of clinically significant results in person.
  • Use recalls and reminders to proactively contact patients about their care

RACGP Standard 5.3 Clinical handover

  • Lack of, or inadequate, transfer of care is a major risk to patient safety. It can result in serious adverse patient outcomes.
  • Potential issues around delayed treatment, delayed follow-up of significant results, medication errors, repeats of tests. They can all result in legal action.

NSQHS Standard 6 Clinical handover

  • Document the structured clinical handover process
  • Clearly communicate the clinical handover policies and processes to the workforce
  • Provide access to structured clinical handover tools
  • Support the workforce and patients to use structured clinical handover processes and tools.

Medico-legal advice

  • Ensure the content of patient health records is accurate and up to date, including any lifestyle risk factors. Health records should include:
    • How long a patient has been attending the practice.
    • The management planning, preventive health interventions and referrals made for a patient.
  • Evidence of care provided by other healthcare professionals for long-term patients.
  • Have a system to store patient health information that is sucre and compliant with relevant privacy legislation.
  • Understand your legal obligations when collecting information about sex, gender, variations of sex characteristics and sexual orientation.
  • Timely review and action on tests and results:
    • How long a patient has been attending the practice.
    • The management planning, preventive health interventions and referrals made for a patient.
    • Evidence of care provided by other healthcare professionals for long-term patients.
    • Notify patients when a practitioner leaves the practice.
    • Look back and review previous patient entries and test results.
    • A patient sitting in front of you, even in a one-off consultation to get a prescription – is your patient and you have a duty of care.
    • Failure to adequately do a handover to another practitioner or institution potentially gives rise to an adverse outcome.

MIPS resources



[1] Wright M. (2018) Continuity of care. Australian Journal of General Practice. 47(10): 661

[3] Gray, D. J. P., Sidaway-Lee, K., White, E., Thorne, A., & Evans, P. H. (2018). Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ open, 8(6), e021161.

[4] Welberry, H. J., Jorm, L. R., Schaffer, A. L., Barbieri, S., Hsu, B., Harris, M. F., ... & Brodaty, H. (2021). Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners. Medical Journal of Australia, 215(3), 130-136.

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