RiO Handbook & Quick Reference Guide

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RiO Handbook

&

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1. Introduction

• What Is RiO? 3

• Benefits of RiO to Staff 3

• Benefits of RiO to Service Users 3

• Information Governance 4

2. Quick Reference Guides

• Logging On / Logging off 5

• RiO Toolbar 6

• Search 1 – Local Searching 7

• Search 2 – National Searching 8

• Search 3 – Advance National Trace 9

• Case Record 10

• Referrals (Entry/Exit) 11

• Caseload 12

• Caseload Transfer 13

• Creating a Local Record From The National Record 14

• Updating National Record To Match Local RiO Record 15

• Postcode Database Key Problem 16

• Progress Notes 17

• Printing Progress Notes 18

• Care Planning – Adding a new care plan 19

• Client Diary & Client Death 20

• HCP Diary - Booking Appointments 21

• HCP Diary – Outcoming Appointments & Cancelling appointments 22

• Clinic Appointment Booking & Appointment Outcome 23

• Clinic Plan, Clinic View & Cancel Appointment 24

• Printing Clinic Lists 25

• Document Upload 26

• Edit & Print Letters 27

3. Appendices

• Ward Management 28

• Mental Health Reports 29

• Safeguarding Children & Adults 37

• Progress Note Guidance 40

• Mental Health Forms 41

• RiO Staff Code of Practice 52

• RiO guide to using ICD-10 59

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1. Introduction

What is RiO?

RiO is part of the National Programme for IT. It is an electronic service user record system, designed to replace the existing systems in u se, PAS. ePEX, PARIS and Care First 6.

Benefits of RiO to Staff:

• Provides staff with access to live, up-to-date electronic records, notes, care plans, bed

plans and risk assessments, through the use of a 'Smartcard' and unique PIN

• Reduction in the amount of paperwork staff need to complete, as all referrals, clinical

notes, care plans and more, will be completed electronically

• More than one user will be able to access one service user’s record at any time, from

any networked location in the Trust

• Increased security with all information and notes kept electronically in one safe place,

coupled with the level of access granted to staff based on what information they need to do their job fully

• Allows staff to communicate more effectively within teams, and across the Trust,

particularly regarding service user care plans and referrals

• The elimination of problems such as illegible handwriting and duplication

Benefits of RiO to Service Users:

• RiO will keep all service user records and notes in one safe and secure place,

improving security as files will no longer need to be moved between sites

• By enabling staff to communicate quickly and more effectively across the Trust, RiO

should provide a more complete and consistent level of care. Staff will be able to quickly access care information when it's needed, resulting in safer diagnosis and treatment for service users

Please note:

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Information Governance

Information Governance ensures all service user records are kept confidential and personal. Everyone in the Trust has a responsibility for protecting service user, carer, staff and volunteer’s information regardless of job role or position. This involves ensuring that all information is stored safely, stays private and is accessed appropriately. To achieve this, all employees must act in compliance with Clinical Governance, the Caldicott principles and the Data Protection Act 1998. The Caldicott principles and the Data Protection Act 1998 are

summarised below:

• Keep personal information secure: do not share your passwords or pin-code with

anyone. Remember to ‘Log-out’ when you have finished using the computer.

• Keep personal information confidential: Justify your reasons for accessing the

information and only disclose to those who need to know. Do not discuss personal information about your service users in corridors or lifts! Keep personal files in a locked area.

• Ensure the information you use is obtained fairly: let the service user know the reason

their information is being stored and who will be able to access their information in compliance with the Data Protection Act (1998).

• Make sure the information you are using is accurate, relevant and up-to-date by

checking personal information with the service user.

• Use the information in an ethical way, i.e. for the purpose it was given.

• Obtain service user consent before sharing their information with other agencies.

• Comply with the law and remember the Trust policies and procedures for safeguarding

information.

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2. Quick Reference Guide

• Logging On

Insert Smartcard to display Passcode dialogue box.

Select job role (this is only required if you have more than one contract with DHFT or are employed with more than one Trust).

• Logging Off

ALWAYS ensure you click on before removing your Smartcard.

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RiO Toolbar

A Back button, which is only visible after you have moved away from your home page – it is not there when you first log on because there is nowhere to go.

A Help button. Click this to see help for your current location.

About An About hyperlink. Click this to see copyright and other details about the system.

A Printer button.

Caseload Your current location.

A Reset Timeout button – this is described in lesson about logging on to RiO.

Anne Jones Your name.

CHTRAIN The system you are using – either the training or the live environment.

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Search 1 - Local Searching

1) Click on the Client Record icon and select Case Record. 2) Demographics (Search) screen is displayed.

3) If you have it, search using the NHS number and click on the Go icon.

4) If you do not have the NHS number enter as much information as you have available i.e. family name (surname), given name (first name), gender, date of birth and postcode.

5) If client found click on their name to view their demographic details.

OR

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Search 2. National Searching

1) To conduct a National Search the box below will require Family Name, Date of Birth and Gender as the minimum search requirement.

2) If a simple trace of the national record does not return a match, the user has the option to perform an advanced trace search. If client found click on their name to view their demographic details.

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Search – 3. Advanced National Trace Searching

1) When a simple trace of the national records returns no match, the following message is displayed.

2) Click Yes to perform an advanced trace. An advanced trace can return multiple possible matches and will search historical information.

3) If the client record is not located nationally, contact Applications Service Desk on 01392 675679 to register a new client. Be ready to provide as much detail about the client’s demographics as you can.

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Case Record

1) Click on the Client Record icon and select Case Record.

2) Search for the client and select a reason for accessing the client’s case record. Record any comments as appropriate and click on Save.

3) Case Record screen is displayed.

• The top left area of the screen allows you to access/record Alerts and view

consent (RiO Consent is now recorded by GP’s only. Please note that Carers’ information and non healthcare information does not require consent to be recorded on RiO.

• The bottom left area of the screen displays key client demographic information. • The right area of the screen displays folders that allow you to access various

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Referrals (Entry/Exit)

1) From the Client’s Case Record select Client Referrals and Entry/Exit from the right hand side.

2) The client’s Referrals screen is displayed.

3) Click on Create New Referral at the bottom of the screen to enter a new referral.

4) Complete all mandatory (green) fields.

5) Referral Received date needs to be completed with the date the referral arrived at the service. Referral Accepted date should be left blank.

N.B Referrals are predominately sent to teams rather than individuals, therefore the HCP Referred To field should be set to NONE.

Other referral options:

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Caseload

1) Click on the Client Record icon and select Caseload.

2) Caseload screen is displayed for the default Health Care Professional (HCP).

3) The details of the clients on the HCP’s caseload are displayed in the main area of the screen.

4) To view another HCP’s caseload, select a different HCP from the drop-down list at the top of the screen and click on GO.

5) To allocate a client who has been referred to the team to a HCP, click the radio button in the Alloc. column and select Allocate. Choose the HCP you wish to allocate the client to and save.

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Caseload Transfer

1) Click on the Client Record icon and select Caseload Transfer.

2) Select the correct team and click on GO.

3) Select the HCP from whom you wish to transfer clients and click on GO.

4) Caseload Transfer/Allocation screen is displayed.

5) Select the HCP to transfer to from the Allocate To list.

6) Enter a transfer Start Date.

7) To share clients with another HCP, put a tick in the checkbox next to the correct client(s) in the Share column.

OR

To reallocate clients to another HCP, put a tick in the checkbox next to the correct client(s) in the Reallocate column.

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Creating a local record from the national record

Used for individuals new to RiO but already registered on the National Database.

1) Select Registration from Client Record icon and search for client. If no record found locally carry out a national search. If client exists Nationally then select them.

2) The Client Details page is displayed, showing sections for Local Data and NCRS National Data.

3) Yellow highlighting will indicate the fields which contain data. There will be no data held locally at this point.

4) Click the checkboxes on the right side of the dividing line to select the national information to transfer to the local record.

5) The Person’s Role will be selected as client by default, change as required.

6) Select an Ethnicity from the drop-down list in the local data section.

7) Click Save to Local Only.

8) The Client Details page is displayed, showing both local and national copies of the information.

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Updating national record to match local RiO record

Used when the client is already registered locally and nationally and some details require updating.

1) Using Registration search for the client and select.

2) The Client Details page is displayed, showing sections for Local Data and NCRS National Data. Click Edit this Client.

3) Change demographic details as required using the Local Data side.

N.B. You can no longer change the GP details, this must be done by the GP.

4) When finished click Save to Local and National.

5) A message is displayed warning that you are about to update the central record. Click Yes to continue.

6) The new information is displayed on both sides of the dividing line.

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Postcode Database Key Problem

1) Initially all locally held address records on RiO will be missing the postcode database Key. The database key is required by V5 RiO as it identifies the client’s home as opposed to just part of the street. Such information should hopefully resolve some address mistakes.

2) Enter the Local and National Database synchronisation screen (see Synchronisation section). If address is highlighted as a problem area, select the Address tick box on the Local Database side. The following message is displayed.

3) Press OK.

4) If the address displayed is complete and correct simply press Search. 5) The address is now displayed. Press Accept Address to confirm.

6) Click Save to Local & National to update both the locally held RiO record and the National Record.

7) You will now be advised that “Saving changes will update the Spine – continue with save?” – this is correct

8) If you get an error message, click Yes. You might get a second error message; also click Yes

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Progress Notes

1) Select Progress Notes from Case Record Screen.

2) Click on Add New Note to create a new progress note.

3) Enter the text of the progress note.

4) If applicable identify the following areas.

3. This Note Contains Third Party Information (tick box). 4. This is a Significant Event (tick box).

5. Add to Risk History (tick box & select Risk Type(s)).

5) If you wish to validate the note, tick the Validate this Note box.

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Printing Progress Notes

1) In the Case Record select Client Related Data-Views and then Progress Note View.

2) Select required service using Progress Note Type.

3) Specify Start Date and End Date.

4) Press OK.

5) Requested Progress Notes are now displayed on the screen and can be printed using the Print button available at the bottom of the screen.

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Care Planning - Adding a new care plan

1) From the Case Record screen, click on the Care Planning folder, select Care Plan. 2) Care Planning – Client screen is displayed.

3) Click on New Problem/Need.

4) Select the Problem/Need type and enter a description of the problem you wish to add.

5) Click on Save and then Care Planning to return to the main care planning screen. 6) Click on the displayed problem to select, then click on New Goal/Intervention. 7) Enter relevant information about the intervention.

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Client Diary

1) Within the clients Case Record select Client Related Data- Views and choose Client Diary View.

2) Select the type of appointment and correct date range using the calendar icons then click on GO to view appointments.

Note: Click on the REF - 1 hyperlink (located at the end of each appointment) to identify Team/Speciality and other referral details.

Client Death

1) Registering a client is now done centrally. To Record client death please ring Applications Service Desk on 01392 675679

Important Note:

Upon disclosure of death staff should immediately make sure all Progress Notes, Diary & Clinic Outcomes etc are complete.

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HCP Diary – Booking Appointments

1) Click on the Appointments icon and select Diary.

2) Check & select the correct HCP and Date and click on GO.

3) Click a Time alongside a vacant slot in your diary and Search for the client.

4) Ensure the following details are correct: a. Appointment Type.

b. Location.

c. Intended Duration.

d. If this is an appointment with a carer, select Carer Appointment. e. If this is not a face-to-face contact, clear this box.

5) Click on Book Appointment to create the appointment in the HCP’s diary, then click on HCP Diary View to return to the diary.

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HCP Diary – Outcoming Appointments

1) From the HCP Diary, click on “To outcome” (this will only appear on the current day, or days in the past)

2) On the following screen, click on the golden “O” 3) You now get the following additional fields:

4) Complete the Seen time and the Outcome (from the drop down list) and any comments that you wish to make.

5) The following screen is then displayed:

6) Click on View if you wish to see the previously entered outcome.

HCP Diary – Cancelling Appointments

1) From the HCP diary, Click on the time next to the appointment 2) Click on “Cancel”

3) Enter the cancellation reason 4) Click on “Cancel this appointment”.

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Clinic Appointment Booking

1) From the Clinic View screen, click on the start time of the slot you wish to book.

2) Search for the client.

3) Ensure the following details are correct: 6. Appointment type

7. HCP

8. Intended Duration

4) Click on Book Appointment to create the appointment.

Clinic Appointment Outcome

1) From the Clinic View screen, click on the small black arrow in the Outcome column.

2) Click on the golden O button.

3) Enter an Arrival Time, Actual Duration and Seen Time, then select an Outcome and click on Save.

4) To view an outcome in more detail from the Clinic View, click on the outcome text.

Please Note:

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Clinic Plan

1) Click on the Appointments icon and select Clinic Plan. 2) Clinic Plan screen is displayed.

3) Select the correct clinic and click GO.

4) Enter the Start Date of the first session you wish to view, select the number of Clinics you wish to view then click on GO.

• Click on a free slot in a clinic to book an appointment into that slot.

• Click on the date of a clinic session to view the clinic for that day in detail.

Clinic View

1) Click on the Appointments icon and select Clinic Appointments. 2) Clinic screen is displayed.

3) Select the correct Clinic ID and click GO. 4) Select the correct Date and click GO.

A clinic view will be displayed for the clinic on the selected date.

Cancel Appointment

1) From the Clinic View screen, click on the Appointment Start Time (for the client appointment you wish to cancel).

2) Clinic Appointment Details screen is displayed. 3) Click on Cancel.

4) Enter a Cancellation Reason and click on Cancel This Appointment. Please Note:

Clinic appointment booking & outcome procedures may differ locally. Please check your operational policies.

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Printing Clinic Lists

1) In RiO select Appointments icon and choose Clinic Appointments.

2) Select appropriate Clinic ID and press Go.

3) Choose Date of clinic you require printing and press Go.

4) The requested clinic day is displayed including the Print Clinic List Button displayed below.

5) The clinic list information is transferred to a more printer friendly screen with the option to select printer.

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Document Upload

1) In the Case Record click Clinical Documentation.

2) Select Document Upload to upload a document (Select Document List View to view previously uploaded documents.)

3) Document Upload screen is displayed.

4) Click on Browse to search for the file. 5) Complete fields:

• Author

• Document Title - name of document e.g. “GP Letter” and a date e.g. “20100302”

in less than 22 characters total.

• Document Type

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Edit & Print Letters

1) In the Case Record click Clinical Documentation. 2) Select Editable Letters.

3) Select the correct Letter Type from the list and click on GO to generate the letter in Word.

4) The letter selected will be displayed in Word (available from the taskbar), with the relevant client details included.

5) You can now make any necessary amendments to the letter and print or save it as you would a normal Word document.

6) To send the letter back into RiO, click on the Send to RiO icon in Word. 7) Complete the standard document upload fields.

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3. Appendix 1 – Ward Management

Vacant Bed Occupied Bed Occupied –

Leave Planned Bed Blocked On Leave – Bed Vacant Blocked – Leave Planned On Sleepover – Vacant Bed Closed.

AWOL Bed (Mental Health) Error Bed

(Two patients admitted at same time)

If two clients/patients are admitted to a bed (one on leave or on sleepover), details for both of them are displayed to the right of the bed:

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Appendix 2 – Mental Health Reports

7 days 48 hours follow - up monitoring

Description Monitor follow-up after discharge, identifying any unfulfilled requirements. Report primarily intended for use by Clinical Team Manager.

This report opens in a new window.

Criteria Start Date refers to the planned date of discharge recorded on the Pre-Discharge Planning form so only clients/patients with a planned discharge date on or after the Start Date are included in the report.

End Date is the actual date of discharge. Only clients/patients with an actual date of discharge on or before the End Date are included in the report.

To be included in the report, clients/patients must have:

Is follow up needed? set to Yes and a value specified for Within 7 days or 48 hours? in the Pre-Discharge Planning form.

At least one appointment on or after the date of discharge.

The report only displays information for wards and caseloads appropriate for the person running the report.

Display The client’s/patient’s name and ID, the actual discharge date, planned discharge date, an indication of whether a follow-up appointment is needed (yes or no) and the elapsed time (7 days or 48 hours) are displayed for all clients/patients. The date, type, team and HCP associated with each appointment are shown. If an outcome has already been recorded for an appointment, details of that are displayed too.

Bed Availability by Hospital Site

Description The current bed availability across a hospital site, sorted by ward and by bay within ward.

Criteria Hospital Site: either select a specific hospital site or leave the default of All to include all sites.

Bed Type: either select a bed type or leave the default of All to include all bed types.

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Display A separate row is created for each bay in each ward, showing:

The broad patient group and clinical intensity of the ward.

The name of the hospital.

The name of the ward – this is a hyperlink that opens the Bed Layout View of the ward.

The bay number.

For each bay (row), the numbers of the following are shown:

Total available (not closed) beds.

Clients/patients on leave.

Bed availability.

Intended discharges.

Expected admissions.

Bed Availability by Ward

Description The current bed availability for a ward, sorted by bay within that ward. This report opens in a new window.

Criteria Select Ward: either select a specific ward or leave the default of All to include all wards.

Bed Type: either select a bed type or leave the default of All to include all bed types.

Displays The information displayed is exactly as described in Bed Availability by Hospital Site, filtered to show one row for each bay in the selected ward(s).

CPA Levels Approaching Review Date

Description Clients/patients whose CPA reviews are due in a specified number of days. This includes reviews scheduled for dates before the current date that have not had an outcome recorded.

Criteria Number of days to next review: everyone who has a review scheduled up to this number of days from the current date is included in the report.

CPA Level: either specify a level or leave the default of All to include everyone who has a review scheduled within the time frame.

Display The report shows the clients’/patients’ name and RiO IDs, the CPA levels they are currently on, the names of the care co-ordinator and allocated HCP, the name of the allocated team and the scheduled review date.

If the review date has passed and no outcome has been recorded for a review, the review is marked as Overdue.

You can order the report by clicking on any of the column headings. Clicking on the same heading a second time reverses the sort order.

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Current Delayed Discharges

Description A report showing clients/patients whose discharges have been delayed. This report opens a new window.

Criteria Select Ward: either select a specific ward or leave the default of All to include all wards.

HCP: either select a specific HCP or leave the default of All to include all HCPs.

Display Basic demographic information about the client/patient is displayed (name, RiO ID, NHS number, date of birth, sex, ethnicity), taken from the demographic record. Information about the admission (date and time of admission, consultant and ward) are taken from the current inpatient event.

The date discharge was planned, the reason for the delay, who is responsible for the delay and the number of days discharge is delayed by are taken from information entered on the Delayed Discharges form.

In-Patient Activity by Site

Description A report showing the number of client/patient movements for all wards within a selected hospital site or across all sites.

This report opens a new window.

Criteria All movements taking place on or after the Start Date and on or before the End Date are counted for the report.

Hospital Site: either select a hospital site or leave the default of All to include all sites.

Display A row is created for each ward showing the number of admissions, discharges, transfers in and transfers out.

In-Patient Activity by Ward

Description A report showing the number of client/patient movements for a single ward or across all wards.

This report opens a new window.

Criteria All movements taking place on or after the Start Date and on or before the End Date are counted for the report.

Select Ward: either select a ward or leave the default of All to include all wards.

Display A row is created for each ward showing the number of admissions, discharges, transfers in and transfers out.

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List of Active Clients

Description A list of referrals relevant to the current user, which could be used for regular review meetings by team leaders and care co-ordinators.

Criteria The list of teams in Select HCP team to filter by is restricted to the teams to which the user has access. ALL is every team in the list, not every team in RiO. The results are restricted to caseloads and wards that the user has access to view.

Display Basic details (client/patient name, RiO ID, GP and practice) from the client’s/patient’s demographic record.

Date of the referral letter, urgency, referral reason, source and referrer and the team from the referral record.

The HCP who has been allocated this client/patient.

The client’s/patient’s CPA level from his or her CPA record.

The date of referral screening (date of assessment) and the referral screening outcome recorded in the Referral Screening form associated with this referral.

Time Since Last Seen

Description A list of clients/patients who have not been seen and do not have a face-to-face appointment within a specified number of days since the last appointment. This report is intended to help care co-ordinators and other clinicians to ensure that clients/patients are seen at an appropriate frequency.

Criteria Number of days since last appointment: only clients/patients who have passed this number of days (1–15) since their last appointment are included on the report. The report will only display clients/patients from caseloads or wards to which you have access.

Clients/patients are not included on this report if their most recent appointment is within the number of days specified unless the appointment was cancelled or the outcome was recorded as DNA. Telephone contacts are not classed as valid appointments for the purposes of this report.

Display Client’s/patient’s name – a link to the Case Record.

The date the referral was received.

The name of the care co-ordinator and the CPA level of the client/patient.

The team and HCP allocated to this client/patient.

The date of the most recent appointment for this referral, the number of days that have elapsed since, the appointment type, the appointment outcome (if any) and the date and time of the next appointment (if any).

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List of Clients without a CPA Review

Description A list of clients/patients who do not have a CPA review within a specified number of days since the last review. This report is intended to help care co-ordinators and other clinicians to ensure that CPA reviews are carried out at an appropriate frequency.

Criteria Number of days since last review: only clients/patients who have passed this number of days since their last review are included on the report.

CPA Level: only clients/patients with this CPA level are included on the report. Leave the default of All to include all CPA levels.

The report will only display clients/patients from caseloads or wards to which you have access.

Display Client’s/patient’s name – a link to the Case Record.

The date of the last CPA review, the name of the care co-ordinator and the CPA level of the client/patient.

The date that the most recent intervention was added to the client’s/patient’s care plan – this forms a link to the care plan.

Dates of the most recent risk assessments – standard risk assessment or the HCR-20 – forming links to the relevant forms.

The date the crisis plan was last amended.

The team for this client/patient.

The date the next review is scheduled, if any.

Missing Data

Description This report displays clients/patients who are missing important data from their records. It can be used by service/team managers and system administrators. The report only displays clients/patients from caseloads or wards to which you have access.

Criteria The two parameters are used to filter the results by surname. Specifying the same letter in both fields restricts the results to clients/patients whose surnames begin with that letter.

Display Lists all clients/patient who have missing or incomplete data in the following fields: given name, NHS number, date of birth (including an estimated date of birth), marital status, sex (including ‘unknown’), ethnicity (including ‘not stated – not requested’), CPA level, GP (including ‘unknown’ GP codes of G99999998), post code (including ZZ99), care co-ordinator and past appointments without a recorded outcome.

To help in obtaining the missing information, the client’s/patient’s daytime telephone number is displayed, as well as the date that registration details were last updated and the name of the person who updated them.

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Staff directory

Description A list of members of staff by service and team.

Criteria You can choose to view all staff for a particular service (or All to see staff for all services) and for a particular team (or All to see staff for all teams).

Display For each member of staff, the report displays the person’s full name, profession, whether or not this person is a care co-ordinator, the staff professional group to which this person belongs and the service(s) and team(s) associated with this person. Also shown are the person’s work-based contact details (phone number, mobile number and email address).

Unencoded FCE's

Description This report lists all finished consultant episodes that are not associated with a confirmed diagnosis.

Criteria Select the consultant whose caseload you want to view. The list of consultants available to you is restricted to those whose caseload you have access to – and your own clients/patients, if you are a consultant. Selecting All is equivalent to selecting every consultant whose caseload you have access to: it does not select every consultant specified in RiO.

Display This report displays the client’s/patient’s full name, RiO ID, NHS number, date of birth, sex and ethnicity from his or her demographic record.

Details of the last confirmed FCE for the client/patient are displayed, including the way in which it finished (discharge or transfer), the consultant responsible at the time, list of confirmed diagnosis codes, date when the diagnoses were confirmed and the person who confirmed them.

A separate row is then displayed for each unconfirmed FCE for the client/patient, showing the name of the consultant responsible (which forms a link to the diagnosis page) and a list of eligible diagnoses (entered but not confirmed).

User Roles and Descriptions

Description This report is used by system administrators. It lists user roles and their corresponding descriptions.

Criteria There are no user-set criteria.

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Waiting List - Allocation to Assessment

Description This report lists clients/patients on an HCP’s caseload who are awaiting assessment. Clinicians can use this report to establish assessment priorities. This report opens in a new window.

Criteria At Date: all clients/patients with open referrals at this date who have not been assessed are included on the report if they meet the other criteria.

Urgency: specify the urgency of the referral using the drop-down list. This enables clients/patients with more urgent referrals to be prioritised. Leaving this at the default of All ignores urgency when selecting clients/patients for the report.

Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral without an assessment are displayed on the report.

You will only see clients/patients on caseloads or wards that you are authorised to view.

Display The report displays basic demographic information for the client/patient, sufficient information about the referral to be able to identify it and the client’s/patient’s CPA Level and Care Co-ordinator from his or her CPA record.

The time between allocation to an HCP and completion of assessment is calculated and displayed.

The report is sorted by urgency and then by decreasing waiting time.

Waiting List - Referral to Allocation

Description This report lists clients/patients who have been referred but are not yet allocated to an HCP.

Criteria At Date: all clients/patients with open referrals at this date who have not been allocated to an HCP may be included on this report if they meet the other criteria.

Urgency: specify the urgency of the referral using the drop-down list. Leaving this at the default of All ignores urgency when selecting clients/patients for the report.

Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral without an assessment are displayed on the report.

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Waiting Times - Allocation to Assessment

Description This report lists clients/patients on an HCP’s caseload who have been assessed. This report can be used to monitor waiting times against local or national targets. This report opens in a new window.

Criteria At Date: all clients/patients with open referrals at this date who have been assessed are included on the report if they meet the other criteria.

Urgency: specify the urgency of the referral using the drop-down list. This enables clients/patients with more urgent referrals to be prioritised. Leaving this at the default of All ignores urgency when selecting clients/patients for the report.

Target Assessment Outcome Time (days): only clients/patients who waited longer than this period of time from referral without an assessment are displayed on the report.

The time between allocation to an HCP and completion of assessment is calculated and displayed.

The report is sorted by urgency and then by decreasing waiting time.

Waiting Times - Referral to Allocation

Description This report lists clients/patients who have an open referral on the date specified and have been allocated to an HCP. The time from referral to allocation is calculated and displayed on the report.

Criteria At Date: all clients/patients with open referrals at this date who have been allocated to an HCP may be included on this report if they meet the other criteria.

Urgency: specify the urgency of the referral using the drop-down list. Leaving this at the default of All ignores urgency when selecting clients/patients for the report.

Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral before being assessed are displayed on the report.

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Appendix – 3 Safeguarding Children and Adults

Safeguarding Children – in relation to RiO (10/05/2010)

This document is intended as a guide to how safeguarding issues are recorded in RiO – reporting and other actions should be taken in line with the Trust policy and direct communication with colleagues is still

required.

As part of the initial assessment process, it is important to record family details particularly children for whom the client has caring responsibilities (parental or otherwise). However, the case record should be added to whenever information regarding relationships with children comes up and risk assessment should be an ongoing process at every contact.

Where to record relevant information: 1. Case Record Front Page

Client Demographics (Right side of front page):

Select family management, click ‘add members’ – this will allow you to search RiO/Spine and pull through demographic details of family members.

Dependants – clicking on this hyperlink on the left side of the case record front sheet will allow you to add dependants to the record. Click ‘Edit this Client’ and ‘Add New Contact’. You must select ‘dependant’ from the first drop down menu in order for the name and relationship to appear on the front page of the case record. More than one dependant can be added in this way.

2. Referral screening – use the risk box to identify any risk issues relating to children if known. 3. Core Assessment Part 2 – Ongoing. There are a number of forms where information should be recorded depending on the situation.

Under ‘Personal and Social Information’

a) Personal and social information form – use relationship section to record relationships with children either their own or those of friends and family. A Genogram should be uploaded at this point. 1

b) Care Management Form – this allows you to identify that the person needs additional support to parent children and to record the support network e.g. child care arrangements. Where the need for additional support to parent children is identified, the action to be taken must be identified through care planning and referral to / liaison with the relevant agencies depending on need and in line with existing policies.

Under Mental Health Act & Children’s Legislation

a) MH Act & Children’s Legislation Form – use this to identify if the client themselves is under 18 and on the Child Protection Register (CPR)

b) Identify if they are a parent or carer for a child on CPR (the caring role may be informal and infrequent but still requires recording) and complete the details section.

c) Any other dependant issues can also be recorded on this form e.g. vulnerable adults, pets etc.

Forensic History

For use when there is a known history of offending. 4. Risk Assessment

a) Identify if the client is a risk to children and provide details regarding the nature of this risk b) Identify if they are on the Sex Offenders register/ Schedule 1 etc

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Safeguarding Summary Form is intended for use when the client is under 18 and should not be used otherwise.

5. Care Planning

Where a risk to children is identified it should be included in the care plan and could be linked to areas of need such as: child care, family relationships, risk to others, sexual offences etc. The intervention type selected should be Adult Generic – Safety & Risk Management.

6. Crisis and contingency planning should include the action to be taken with regard to dependents in the event of a crisis.

7. Progress Notes

All concerns and actions in relation to safeguarding children in relation to a particular client must be documented immediately in the progress notes and the existing policy for reporting concerns should be followed. Progress notes should be linked to problems types as described above. The 3rd party information box should be ticked as appropriate. The progress note should be linked to risk if the client poses a risk or is at risk themselves. If you are recording reporting a child in the client’s family as at risk but not from the client, this might need to be linked as a significant event if it is likely to impact on the client’s well being or relationship with services.

NB if any progress note is linked to risk, the risk assessment also needs to be updated.

Safeguarding Adults (10/05/2010)

As with safeguarding children, this document is intended only to inform staff of when and where to record this information in RiO. All other processes including liaison with colleagues and external agencies should follow Trust policy and good practice guidance.

1. Case Record Front page

There is a hyperlink in bold red to the latest risk information in the case record. This may be a risk assessment or a progress note that has been linked to risk. Keeping the risk assessment up to date and linking relevant progress notes to risk ensures that all clinicians within DPT who are working with the individual can access up to date information to support their practice.

2. Referral Screening/ Triage

Use the risk box to record any relevant information that is known at this stage.

3. Core Assessment Part 2 – Ongoing

Information regarding safeguarding, particularly from the person’s history may be recorded in a number of the forms here.

Under ‘Personal and Social Information’

a) Personal and social information form – use family history section to record relationships within the family including those which present safeguarding issues. A Genogram should be uploaded at this point. 2 b) Relationships and Sexuality – use this form to record current relationships and history of those and other

prior relationships.

Under ‘Care Management’

a) Accommodation/Housing – record others living with the person and any issues regarding these arrangements e.g. if they are unable to get a guest to leave, or the accommodation is being misused.

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b) Finance – Record if there are issues regarding financial abuse including by those with legal powers over the person’s finances.

Under Mental Health/Children’s Legislation

a) If an adult protection register is in use and the person is on it, then that can be recorded here. This will then appear on the front of the case record.

b) If the person has dependents this should also be recorded here. This information also needs to be recorded via the front page of the case record using the hyperlink Dependants on the left side of the case record front sheet which will allow you to add dependants to the record. Click ‘Edit this Client’ and ‘Add New Contact’. You must select ‘dependant’ from the first drop down menu in order for the name and relationship to appear on the front page of the case record. More than one dependant can be added in this way.

c) In the case of domestic abuse situations where children are involved the risk to them should also be recorded on this form and elsewhere as indicated in Appendix 2.

Under Mental and Physical Health Examination

Where a physical injury is reported and observed, a body map annotation should be created to indicate the location and nature of the injury. Details of the incident reported should be recorded in Risk Information, Risk Incidents and/ or in a progress note which is linked to Risk History.

4. Risk Assessment

This should be used to record risk of harm from others including domestic violence. The level of risk and the buffers should be identified in the summary box. The risk management plan forms part of the care plan.

5. Care Planning

Care plans in relation to safeguarding issues should be linked to the appropriate need e.g. risk from others and the intervention type should be Adult Generic - Safety & Risk Management.

6. Crisis and Contingency Planning

Should include the actions to be taken in terms of involvement/ non-involvement of others in the event of a crisis. Where the person is potentially at risk from their nearest relative and wishes to displace them, this should be recorded under Mental Health Act, Nearest Relative.

7. Progress Notes

All concerns and actions in relation to safeguarding in relation to a particular client must be documented immediately in the progress notes and the existing policy for reporting concerns should be followed. Progress notes should be linked to problems types as described above. The 3rd party information box should be ticked as appropriate. The progress note should be linked to risk if the client poses a risk or is at risk themselves.

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Appendix 4 – Progress Note Guidance

PROGRESS NOTES – GUIDANCE (10/5/2010) 1. INTRODUCTION

1.1. Health and Social Care records should be contemporaneous, accurate and provide a comprehensive record of the implementation and effectiveness of interventions that utilise strengths and address assessed needs as set out within the person’s care plan. In addition, the notes should be written in accordance with Professional Guidance. As a minimum Devon Partnership Trust expects staff to ensure that their notes comply with the following standards:

1.1.1. If a person is supported on an inpatient unit, progress notes should be entered in the person’s record in accordance with the frequency of contact e.g. there should be a progress note on the relevant care plans entered at least once each shift (morning, afternoon and nights)

1.1.2. Community progress notes should be completed as a minimum after each contact. 1.1.3. Staff should ensure that the progress notes include:

1.1.3.1. What the staff saw and heard in relation to the person’s strengths and assessed needs.

1.1.3.2. What the staff perceived and why they perceived it in relation to the person’s strengths and assessed needs

1.1.3.3. Reference to the relevant element of the care plan e.g. CP1 personal care, CP3 therapeutic activity etc.

1.2. A record should be made in the progress notes even if the assessed needs addressed by the care plan does not occur e.g. “Mr Smith has used relaxation techniques, structured activity, (painting and yoga) and conversations with staff to manage his concerns for his family and his anxiety regarding his time on the ward. Mr Smith reports that he has experienced no overt anxiety this morning and is confident that he can continue to use these strategies when he returns home.”

1.3. Specific situational events involving complex, risky and sensitive situations which necessitate transfer of information verbally from one member of staff to another, either within or between agencies, need to be recorded under the SBAR headings i.e. Situation, Background, Assessment,

Recommendations/Decisions.

1.4. Where a record is made in relation to Mental Capacity Act or Best Interest decisions then it should be recorded under the specific heading e.g. Mental Capacity Act with the heading underlined. This will aid identification of those decisions.

1.5. All records should comply with Professional standards – as a minimum they should be dated, timed, signed, legible, written in black ink and include professional status.

1.6. NOTE: referencing the progress note to the care plan will aid tracking and evaluation of the effectiveness of the interventions set out within the care plan. Evaluation will be determined by the person’s and professional’s views on what’s worked well, what’s not worked so well and what needs to change to support recovery. This will then enable a decision to be made about whether the care plan needs to be continued, discontinued or adapted.

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Appendix 5 Mental Health Forms

Presenting Situation

Rationale: This form is used to record the details of the presenting situation related to a particular referral.

Notes: This form is in the Part 1 – Referral Related group.

The Referral/Admission field is a list of all valid referrals and admissions for this client/patient. You must select one to link this information to a particular event.

Current Interventions Including Medication

Rationale: This form is used to record the details of the current interventions, including medication related to a particular referral.

Referral Outcome Decision

Rationale: This form is used to record the details of the outcome of a referral.

Information Sharing and Consent

Rationale: This form is used to record details of a client’s/patient’s consent to share and receive information about his or her care.

Notes: This form is in the Information Sharing and Consent folder in the Part 2 – Ongoing group.

Updated By and Updated On are entered automatically when the form is saved.

Mental Health History

Rationale: This form is used to record the client’s/patient’s mental health history.

Notes: This form is in the Past (Physical & Mental Health) folder in the Part 2 – Ongoing group.

There is only ever one version of this form per event – it can be edited as many times as necessary and changes can be made to the information it contains. A full history is retained.

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Physical Health History

Rationale: This form is used to record the client’s/patient’s physical health history.

Notes: This form is in the Past (Physical & Mental Health) folder in the Part 2 – Ongoing group.

Personal & Social Information

Rationale: This form is used to record personal and social information about the client/patient.

Notes: This form is in the Personal & Social Information folder in the Part 2 – Ongoing group.

Care Management

Rationale: This form is used to record information about care management issues.

Notes: This form is in the Care Management folder in the Part 2 – Ongoing group.

Mental Health/Children’s Legislation

Rationale: This form is used to record legislation and forensic information.

Notes: This form is in the Mental Health/Children’s Legislation folder in the Part 2 – Ongoing group.

Forensic History

Rationale: This form is used to record information about any forensic convictions that the client/patient may have.

Notes: This form is in the Mental Health/Children’s Legislation folder in the Part 2 – Ongoing group.

Substance & Alcohol Use

Rationale: This form is used to record details of the client’s/patient’s use of alcohol and other substances.

Notes: This form is in the Substance & Alcohol Use folder in the Part 2 – Ongoing

group.

Problematic Substance & Alcohol Use Form

Rationale: This form is used to record details of the client’s/patient’s problematic use of alcohol and other substances.

Notes: This form is in the Substance & Alcohol Use folder in the Part 2 – Ongoing

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Mental State Examination

Rationale: This form is used to record results of a mental state examination.

Notes: This form is in the Mental & Physical Health Examination folder in the Part 2 – Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed.

Physical Examination

Rationale: This form is used to record details of a physical examination

Physical Health Assessment

Rationale: This form is used to record details of a physical health assessment.

Physical Monitoring

Rationale: This form is used to record details of a physical monitoring.

Nutrition

Rationale: This form is used to record a client’s/patient’s nutritional state.

BMI is a calculated field, based on the height and weight entered in the two preceding fields.

Total weight loss score and Total weight gain score are also calculated fields – information is displayed indicating the action to be taken, if any.

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Body Map Annotations

Rationale: This form is used to record assessment details by annotating a body map.

Client & Carer’s Understanding of Assessment

Rationale: This form is used to record details of the client’s and carer’s understanding of assessment.

Notes: This form is in the Client & Carer’s Understanding of Assessment folder in the Part 2 – Ongoing group.

Carer 1 and Carer 2 are populated from the client’s demographic record – any changes need to be made there.

Risk Assessment

Rationale: This form contains the results of a risk assessment for the client/patient. It is important to complete all areas of the form even if there is no risk of a particular type to show that every area of risk has been considered.

Notes: This form is in the Risk Information folder and a link to it is present in from the Core Assessments..

Information entered into this form is displayed in the Risk Summary, accessible from the Case Record.

Client HCR-20 Assessment Information displays a summary from the HCR-20 assessment, if one exists.

Formulation Summary

Rationale: This form is used to record details of the Formulation and Summary derived from the completed assessment.

Notes: This form is in the Formulation/Summary folder in the Part 2 – Ongoing

group. This folder also contains a link to the client’s/patient’s Care Plan.

Mental Health General Assessments

Additional Personal Information

Rationale: This form is used for recording information about the referral to the Mental Health services

Notes: To access this form, select Client Demographics on the right of the Case Record page.

You cannot make changes to this form once it has been saved but you can create a copy and edit that version.

Careplan Contact

Rationale: This form is used for recording information about the client’s/patient’s contacts for inclusion in the Care Plan.

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Notes: This form is accessed from within the client’s/patient’s care plan. Click the

Other Information link at the bottom of the care plan and a list of three forms is displayed:

Careplan Contact (this form) Careplan Distribution (see below)

Crisis, Relapse and Contingency Plan (see below).

Careplan Distribution

Rationale: This form is used for recording information about the distribution of the care plan to relevant people.

Notes: This form is accessed from within the client’s/patient’s care plan. Click the Other Information link at the bottom of the care plan and a list of three forms is displayed:

Careplan Contact (see above) Careplan Distribution (this form)

Crisis, Relapse and Contingency Plan (see below).

Carer’s Assessment

Rationale: This form is used for recording information about the client in their Role as the Carer of another service user.

Notes: To access this form, select Role as Carer Information on the right of the Case Record page.

Court Diversion Scheme

Rationale: This form is used to record information where a client/patient has been referred for assessment from a court.

Notes: To access this form, select Client Referrals on the right of the Case Record

page.

The Referral field has a search facility to identify referrals not already linked to a form of this type. Select one to link to this form.

Section 117 Review Information

Rationale: This form is used for recording information about the Section 117 details for CPA Review meetings.

Notes: To access this form, select Care Planning, CPA andReviews on the right of the Case Record page.

NOTE: Old copies of the form that was titled: CPA Review Management will also be listed in the index and can be viewed via this form. CPA review management information is now recorded within the CPA Review functionality.

Crisis, Relapse and Contingency Plan

Rationale: This form is used for recording information about the referral to the contingency plan that is to be used if the client/patient suffers a relapse or a crisis.

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Notes: To access this form, select Care Planning, CPA and Reviews on the right of the Case Record page, then select Care Planning.

This form is accessed from within the client’s/patient’s care plan. Click the

Other Information link at the bottom of the care plan and a list of three forms is displayed:

Careplan Contact (see above) Careplan Distribution (see above)

Crisis, Relapse and Contingency Plan (this form).

Delayed Discharge

Rationale: This form is used to record the reasons for delaying discharge.

Notes: To access this form, select Inpatient Management on the right of the Case Record page.

Police Screening Request

Rationale: This form is used to record information where a client/patient has been referred for assessment by the police.

page.

Pre-Discharge Planning

Rationale: This form is used to record details of pre-discharge planning before discharge from an inpatient bed.

Notes: To access this form, select Care Planning, CPA andReviews on the right of the Case Record page.

Referral Screening

Rationale: This form is used for recording information about the referral to the Mental Health services

page.

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Mental Health Risk Assessment

HCR-20

Rationale: The HCR-20 is an internationally recognised assessment for assessing the risk of violence. (Webster, Douglas, Eaves & Hart 1997). These forms should only be used by Health Care Professionals who have been trained in using the

HCR-20 assessment.

Notes: This is a suite of forms accessed from the Risk Information folder.

Enter the date that this assessment starts in the box on the left and click Start from this date. A list of folders is displayed on the left, each containing one or more forms.

HCR-20 R Factors (in the Step 1 folder) cannot be edited after it has been saved. It works in the same way as the Physical History form described in lesson CR10 – Accessing Forms.

MAPPA

Rationale: The MAPPA form is used for recording details of risk to others.

Notes: This form is in the Care Planning, CPA andReviews folder.

The Inpatient Consultant field contains the name of the patient’s current consultant if the patient is an inpatient.

The drop-down list of client/patient contacts displayed in the Agencies Involved section lists professional contacts recorded as part of the

client’s/patient’s demographic record. The list displays the Contact Type, First Name and Surname for each valid contact

MH1

Rationale: This form is used to record details of a Mental Health Act, MH1 assessment.

Notes: This form is in the MHA folder.

The Referral field is used to link this assessment to a valid referral. Click the search icon to display a list of referrals.

Nearest Relative

Rationale: This form is used to record details of the nearest relative.

A large quantity of information is provided on the form giving guidance about how information entered into the form is interpreted.

Observations

Rationale: This form is used to record details of observations of a client/patient and their family or carer.

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Notes: This form is in the Risk Information folder.

Information entered into this form is displayed in the Risk Summary, accessible from the Case Record.

Client HCR-20 Assessment Information displays a summary from the HCR-20 assessment, if one exists.

Safeguarding Child Summary

Rationale: This form is used to record details of child protection assessment.

Notes: This form is in the Risk Information folder.

Section 117 Eligibility

Rationale: This form is used to record eligibility for Section 117 aftercare under the Mental Health Act.

Specialist Assessments: MOHO OT Assessment

MOHO stands for Model of Human Occupation.

If you select MOHO from Specialist Assessments in Case Record, a list of the four forms in this set is shown on the left of the page.

MOHOST & OCAIRS

Rationale: This form is used by occupational therapists to record the outcomes of the MOHOST and OCAIRS assessments.

Notes: Information on the ratings used is displayed on the form.

OPHI-II

Rationale: This form is used by occupational therapists to record the outcomes of the OPHI-II assessment.

VQ and ACIS

Rationale: This form is used by occupational therapists to record the outcomes of the VQ and ACIS assessments.

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WRI & WEIS

Rationale: This form is used by occupational therapists to record the outcomes of the WRI and WEIS assessments.

Specialist Assessments: NCDS

The NCDS specialist assessments consist of two forms, which are displayed on the left of the page when NCDS is selected. These forms are used to record information required for the NCDS (The National CAMHS Data Set). More information is available about the NCDS at www.camhoutcomeresearch.org.uk.

NCDS Form

Rationale: This form is used to record details required for the NCDS.

Notes: The Referral field is used to link this form to a valid referral for the client/patient. Click the search icon to display a list of referrals.

NCDS Rating

Rationale: This form is used to record ratings required for the NCDS.

Notes:

Specialist Assessments: NDTMS

The information recorded on this set of forms is used, with the demographic information recorded for the clients, to provide data for the National Drug Treatment Monitoring System (NDTMS).

NDTMS - Main Capture Form

Rationale: This form is used to record the main details needed for the NDTMS.

Notes: This form must be linked to a referral to a drug treatment service.

NDTMS Adult Services Modalities

Rationale: This form is used to record adult services modalities information for the NDTMS.