HoNOS stands for Health of the Nation Outcome Scale. CGAS
Rationale: This form is used by Child and Adolescent Mental Health Services to record a score for general functioning.
Experience of Service
Rationale: This form is used to record details of the client/patient’s experience of service.
HoNOS (Working Age Adults)
Notes: The latest score recorded on this form can be automatically entered into a CPA review record.
HoNOS65+ (Older Adults)
Rationale: This form is used to record HoNOS scores for older adults.
HoNOS-ABI
Rationale: This form is used to record HoNOS scores for people with acquired brain injury (ABI).
HoNOSCA
Rationale: This form is used to record HoNOS scores for children and adolescents.
Notes: There are two versions of the HoNOSC available. Current and Pre 2006. These are located in a form set menu when you click on the HoNOSCA link.
HoNOS LD
Rationale: This form is used to record HoNOS scores for people with learning disability.
HoNOS-secure (v.2)
Rationale: This form is used to record HoNOS scores for people held in secure accomodation.
Paddington Complexity Scale
Rationale: This form is used by Child and Adolescent Mental Health Services, to record a score for complexity.
Notes: Reference: Yates P, Garralda ME, and Higginson I. Paddington complexity scale and health of the nation outcome scales for children and adolescents. British Journal of Psychiatry 1999;174:417-423.
Strengths & Difficulties
Rationale: This form is used by Child and Adolescent Mental Health Services, to record a score for strengths and difficulties derived from the Strength and Difficulties Questionnaire (SDQ).
Notes: Reference: Developed by Robert Goodman at the Institute of Psychiatry, who owns the copyright to the SDQ.
Some sections of this form contain a Total score field. This is a calculated field that gives a combined score for all fields in that particular section.
Appendix 6 - RiO Staff Code of Practice
RiO is an electronic record keeping system that ensures clinicians have the complete record of the person they are caring for in a standard format across the Trust.
To realise the full benefits of RiO it is important all clinicians use RiO in the same way and as such this Code of Practice should always be followed. This document has been ratified by the Trusts Head of Professions.
1. Referrals & Patient Contact
What is a recordable contact?
This is largely a matter for individual judgement but a contact does not need to be recorded when very brief and does not make a material difference to the clinical care of the person using the service.
How do I record requests for advice for people not known to the service and are not formal referrals e.g. consultation with a GP for advice who is not asking for the patient to be seen?
This should be recorded in the ‘Referral Screening’ section. A new patient episode should be opened (which takes less than a minute when using an NHS number) and appropriate detail recorded. Not all fields need to be completed. If required, a letter to the GP can be made by ‘cut and paste’ into a standard letter template.
Where should I record referral triaging?
This should be recorded in the ‘Referral Screening’ section. If the person will be assessed it is only necessary to briefly fill in the salient detail and not all fields may be needed to be completed as the referral letter will be the primary source of information. If the triager needs to contact the referrer for more information any additional information should be recorded in the appropriate field in this section. If the person is not to be assessed the reason for the decision should be recorded e.g. “more appropriate for Cruse counselling and discussed with referrer who agrees”.
Where do I record telephone referrals?
Record these in ‘Referral Screening’. Use this template to structure the information from the referrer.
What information should I put into a referral to another DPT team?
As the whole clinical record will be available on RiO to the team receiving the referral you only need to state the reasons for referral and desired outcome.
How do I update a discharged persons record if I see them for a new assessment? You should always use ‘create new’ (referral) record for each section. For some sections e.g. Substance misuse this will bring up the previous record which you should edit according to your new assessment. RiO reduces duplication in this respect. For other sections where you are not adding to history e.g. ‘Mental State’ this will be blank and you will need to complete a new record.
Rapid re-referrals must no longer be used.
To establish a baseline HoNOS, all existing people using the service must have a baseline HoNOS completed as soon as possible after RiO goes live. All new people using the service MUST have a HoNOS completed by either MW&A, UIC or specialist services like Workways at the first assessment.
On discharge, all people using the service MUST have a HoNOS score.
Some teams may decide HoNOS is a useful tool for measuring the effectiveness of their care and may wish to monitor HoNOS scores more frequently.
Where do I enter rating scale results?
You should enter rating scale results in the progress notes and then link this to a rating scale care plan. If you wish to review the scores you need to open the care plan and linked progress notes. The original rating scale should be scanned and the original put in confidential waste.
What category should I use in care planning?
This is important as progress notes are linked to categories so you can filter progress notes. You should pick the category which best reflects the care-planned need (we recognise this is not an exhaustive list and does not best reflect Recovery practice and will be working to improve).
How should care plans be related to need?
Individual needs should have separate care plans. In the past, each person has had a care plan with groups of interventions, however from now on each need should have a separate care plan. Taken together these care plans comprise the recovery care plan. RiO facilitates this approach. All care plans can be viewed in list form which is particularly useful for care planning meetings and ward rounds to ensure there is a discussion about all needs and how they are managed.
What should I add to the progress notes rather than the core assessment?
Any historical information e.g. personal, psychiatric, family should be entered into the core assessment i.e. part 1 and/or part 2 of the assessment. Progress notes should reflect the effectiveness of care plan interventions and any other important information that is not entered into another field.
Which staff will need their records validated?
Only students (nursing, medical, OT etc) and trainee psychologists. Volunteers are considered employees and as such have an honorary contract and will be able to validate their own notes.
When should I tick ‘This is a significant event’ or ‘Add to risk history’?
You cannot tick both. Some events will be automatically added to one or other category e.g. AWOL or CPA review to ‘Significant Events’. There is no absolute guidance as to which to tick but if any in doubt tick ‘Add to risk history’. However, if you do tick risk it will be also added to the significant events!
This is when you record any information about the person you are caring for from another person who is not from DPT. You must tick this box if the third party does not consent to that information being released to the person you are caring for. This box should also be ticked for information not about the person you are caring for but about a significant other e.g. a spouses own mental health.
If I care for a person under MAPPA do I have to fill in the MAPPA fields?