Consultation skills - Preparation for home visits

It is worth planning a home visit before you set out, says Dr Sara Whitburn.

One of the big changes for me when starting my registrar year was incorporating home visits into my clinical practice. By thinking through the steps of a home visit systematically, you can develop a plan to get started.

Practice procedures
Visits are usually scheduled review visits to housebound or nursing-home patients or for patients too unwell to attend surgery. Visits may be requested by other members of the health team who have concerns about a particular patient.

Most surgeries have criteria for home visits, to help control visit workloads. It is worth becoming familiar with the criteria for your practice.

Reception staff should have a system to document visit requests. As a new GP registrar, you need to find out how visits are allocated. There will be days when you need to limit the number of visits you undertake due to other commitments, such as meetings and exams. Let your practice know in advance.

You should make visits with your GP trainer for the first few weeks, and then visit alone with a named GP supervisor available by phone.

Personal preparations
Make sure the practice staff have your mobile phone number. Store important numbers on your phone, such as those for local hospital admission, the ambulance and the coroner.

You will need a doctor's bag. To decide what to include, talk to your supervisor and look at the Oxford Handbook of General Practice.

You are also required to have transport for home visits, and will need to discuss with your insurance company cover for using your car for this purpose. Leave little to identify your vehicle as a doctor's to reduce break-ins, and carry a map or satellite navigator so you don't get lost.

Safety
Patients are usually well known to your practice. If you have concerns based on the patient's medical records obtain as much information as possible before visiting. You may want to ask your trainer or a colleague to go with you.

Safety precautions include:

  • Informing someone of the destination and expected duration of any
  • visit you undertake unaccompanied.
  • Carrying limited quantities of drugs and prescriptions.
  • Locking your car and your bag if left in the car.
  • Considering carrying a personal alarm.
  • Storing emergency numbers in your mobile phone.
  • Asking a family member to meet you on unfamiliar estates.
  • Asking the police to meet you at the address if there is a possibility
    of violence.

Before you leave
It is a good idea to telephone the patient before visiting to identify the exact problem and whether you need additional equipment.

Sometimes an alternative to a visit can be negotiated, such as attending the surgery, telephone advice, a prescription or direct referral to a more appropriate health professional.

Confirm the address and ask for directions if needed. If possible ask your trainer or the patient's usual GP for any further information before visiting.

The visit
Once you have introduced yourself, deal with the consultation as you would in the surgery.

Ask to have the TV or radio turned off so you can concentrate, and try to arrange good lighting with the patient for a full examination.

If you are unsure how to manage the patient you can call your supervisor and even return to the surgery, advising the patient that you will call back with a plan.

Write brief notes on site and leave prescriptions and other paperwork with the patient. Make sure they understand the management plan.

No answer
If there is no answer, check you have the correct address, look through a window and phone from your mobile before assuming the worst.

If there is no response and you are highly concerned, consider calling your local A&E or the ambulance service to check if they are currently dealing with the patient.

If still unable to track down the patient, consider calling the police to help with access.

If you are less concerned then leave a note and telephone the patient later that day.

On your return
It is important that you update the computer and prescribing record as soon as you can.

Replace any drugs or dressings dispensed from your bag. Arrange investigations and referrals, and make sure you document any plans for future visits or telephone contact with the patient.

Dr Whitburn is a GP registrar in Dursley, Gloucestershire

This topic falls under Section 2 of the GP curriculum, 'The general practice consultation': www.rcgp-curriculum.org.uk

References
- Howell S, Radcliffe E, Abrams W. The New GP Survival Guide. Scion Publishing Ltd 2005.

- Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice, Second Edition. Oxford University Press 2005.

Learning points
Steps to take to ensure smooth home visits
1. Familiarise yourself with your practice's criteria for home visits
and prepare your doctor's bag.

2. Check/arrange appropriate car insurance.

3. Inform someone of the destination and duration of your visit and give
the practice staff your phone number.

4. Phone the patient beforehand.

5. Call your supervisor if you are unsure how to manage the patient.

6. Ensure the patient understands the management plan.

7. Update computer records and refill your bag on your return. Clearly document and hand-over plans for future contacts.

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