Standard Operating Procedure Reference Guide

Transcription

1 Standard Operating Procedure Reference Guide Version 1.3 September 2011 Page 1

2 Contents SECTION 1 - INTRODUCTION... 4 SECTION 2 - GENERAL RIO PRINCIPLES Training Requirements Recording Information Accessing appropriate records Business Continuity - RiO Manual Forms... 6 SECTION 3 - ACCESSING RIO & SMARTCARDS Security RBAC (Role Based Access Control) Logging in to the System Smartcard Access: Smartcard Job Roles: Incorrect passcode inserted Passcode resets Logging out Locking your computer Management of Health Records Care Records Guarantee Legitimate Relationships Self Claimed Legitimate Relationship Report PALS (Patient Advice and Liaison Services) Audit Trail Caldicott Guardian Information Governance Guidance for Temporary Staff SECTION 4 THE CLIENT RECORD PDS (Personal Demographics Service) Searching and Registering Unable to Locate a Client Duplicate records Synchronisation Ethnicity Other Demographic Elements S Flagging hiding all patient data for extremely sensitive cases New NHS Number Process and Report on creating a new NHS number Patient Identifiers Local Records Death Process informal/formal Logical Delete Consent to Share Demographic Information Entering mobility and communication issues Entering preferred place of care Entering interpreter requirements SECTION 5 INPATIENT MANAGEMENT Bed (Examples) SECTION 6 ACTIVITY DATA Referral Source Referral Reasons Page 2

3 6.3 Referral Urgency Inappropriate Referrals Registration of urgent referrals Eligibility for Treatment/non eligibility Episode of Care Referral to Assessment Time Assessment to Treatment Time Contacts SECTION 7 RECORDING INFORMATION IN RIO Referral Buckets Student notes rd party information Entering information on others behalf Disclosing patient information Validation Using HCP diaries Recording Appointment Outcomes Outcome Codes Non client related activity Travel Time Notifications Re-direct Notification Clinics Discharge reasons SECTION 8 DEATH OF A CLIENT Recording a death Notifications of death Reversing a death SECTION 9 PROBLEMS WITH RIO Local Back Office Operation Support Hours Incident Process Flow Ridgeway RiO Local Back Office Ridgeway LBO RiO Governance Structure Change requests APPENDIX A GLOSSARY OF TERMS APPENDIX B - REGISTRATION FIELDS WITHININ RIO APPENDIX C RIO SOP CHANGE REQUEST FORM USER GUIDANCE. 28 APPENDIX D THE CARE RECORD APPENDIX E TEAM BUCKETS APPENDIX F LIST OF RA AGENTS APPENDIX G RELEVANT ROLES & RESPONSIBILITIES Page 3

4 Section 1 - Introduction This Standard Operating Procedure (SOP) has been split into two distinct documents A User Guide, detailing the most frequently performed tasks, dividing these up by area, and a Reference Guide which covers everything else. The SOP has been designed as a guide to ensure that all staff can perform their work in relation to RiO in a safe and accountable way. They draw on existing policies and procedures and are based on RiO V5.4. This is a read only document. If you feel that a change should be made to the SOP you need to complete a SOP change request form, see Appendix C and send to RiO Lead, Trust Headquarters, Slade House, Horspath Driftway, Headington, Oxford, OX3 7JH. It is essential that all staff ensure they are familiar with the contents of the Standard Operating Procedures for their area. Deviation from this may result in disciplinary action being taken against the member of staff. This part of the SOP is the Reference Guide Page 4

5 Section 2 - General RiO Principles 2.1 Training Requirements It is a mandatory requirement that everybody who uses RiO is trained and able to demonstrate their competency prior to accessing the system for the first time. If you need training please contact your local Champion User or the Learning and Development team on learning@ridgeway.nhs.uk. Training can be given on a one to one basis so new staff do not necessarily need to wait for a course to be run. The Learning & Development Team can arrange this for you also. All staff must also familiarise themselves with this Standard Operating Procedure prior to accessing the system. Until the above pre- requisites are met a user will not be given access to the Live RiO Database. 2.2 Recording Information All recording of information onto RiO, including Progress Notes and Outcomes, should be done in a timely manner with the aim of completing either at the time of an appointment or on the next working day whenever possible. Where this is impossible and the information needs to be available on RiO, the member of staff can contact a colleague who may input the information in the patient s records, changing the originator of the Progress Note to the colleague who is dictating it. 2.3 Accessing appropriate records Staff must not access records for which there is no valid reason for them to do so. Any person attempting to view records for which they do not have a justifiable reason to do so should be aware that all entries are auditable and their actions may result in disciplinary action being instigated. Any person accessing a client record will be prompted to give a reason for accessing this record if a legitimate relationship has not already been established. (See 3.12 Legitimate Relationships) Page 5

6 2.4 Business Continuity - RiO Manual Forms If RiO is not functioning then RiO Manual Forms (available on the Intranet under the RiO link) should be used to record new patient s demographics so that the patient can be registered on RiO when it is functioning again. Details on activities and outcomes should also be recorded. The manual form should be shredded once the information has been recorded on RiO. Where paper notes are used for domiciliary and inpatients then accurate details of new patients seen should be kept so that they can be registered once RiO is functioning and information inputted on clinic and diary sheets. Page 6

7 Section 3 - Accessing RiO & Smartcards 3.1 Security The Trust has a responsibility to monitor all Information Security incidents that occur within the organisation that may breach security/confidentiality of personal/organisational information. The Trust also needs to ensure that all incidents are identified, reported and monitored. The Trust already has a method of recording untoward clinical incidents but not necessarily non-clinical incidents relating to breaches of security and confidentiality (see Information Security Incident Reporting Policy & Computer Security Policy). The documents detail the process of identifying, recording and monitoring Information Security incidents (sometimes referred to in related literature as non-clinical incidents). This is a requirement of the Caldicott recommendations and BS RBAC (Role Based Access Control) Within an organisation, roles are created for various job functions. The permissions to perform certain operations are assigned to specific roles. Members of staff (or other system users) are assigned particular roles, and through those role assignments acquire the permissions to perform particular system functions. 3.3 Logging in to the System This section introduces you to RiO and outlines the importance of safeguarding the electronic information to which you have access. RiO is a secure system that is password protected. To log in to the system the following procedure must be adopted: No. Instruction Additional Information 01 Log onto your PC as normal 02 Insert your smart card into the smartcard slot on your keyboard or reader, or slot in laptop 03 Enter your Passcode Please keep your Passcode private and Smartcard with you at all times! 04 Screen will now say checking for card and you will automatically be taken to your RiO home page Changing your Passcode: You ll be prompted to change your Passcode just once a year. If you forget your Passcode you will need to liaise with your RA Agent Sponsor (See Appendix F ) to rectify this 3.4 Smartcard Access: RiO v5.4 is a secure system and requires all users to have a smartcard in order to access it. Users have a responsibility to safeguard the electronic information to which they have access. 3.5 Smartcard Job Roles: RiO users should be aware that their ability to view screens within the system will be defined by their user access, which is in turn linked to their job role. Your role on RiO will not always reflect your job title as it is used to indicate access privileges only. Page 7

8 3.6 Incorrect passcode inserted After 3 failed attempts to access RiO, such as inserting the wrong code, your account will be disabled and you will be locked out of the system. If this happens contact your local administrator. 3.7 Passcode resets Most Senior Administrators will have the ability to unlock your passcode if you lock yourself out although depending on your location this may not be possible. Your local administrator will know who can unlock your card for you though. 3.8 Logging out When logging out of RiO, it is vital that users click on the words Log Off at the top right hand corner of the screen before removing their smartcards as this will close all internet sessions being run on that PC. Failure to do this may result in the user being blocked from using RiO. In this event they should telephone the OHIS (Oxfordshire Health Informatics Service) Helpdesk on between 9.00am and 5.00pm, Monday to Friday, or via to service.desk@ohis.nhs.uk. 3.9 Locking your computer Staff should not leave a PC unattended with RiO screens open, even for a brief time. RiO should be logged off or the PC locked using Ctrl+Alt+Delete & selecting Lock Computer or Windows key ( flag key) + L. You will then need to enter your network password to unlock Management of Health Records The policy for managing health records can be found on the Ridgeway Intranet site Care Records Guarantee The Care Records Guarantee is an NHS guarantee and sets out the control a Patient can have over their own records. It covers people's access to their own records; controls on others' access; how access will be monitored and policed; options people have to further limit access; access in an emergency, and what happens when someone doesn t have capacity to make decisions for themselves. Everyone who works for the NHS or for organisations delivering services under contract to the NHS has to comply with this guarantee. The guarantee was first published in 2005 and is regularly reviewed by the National Information Governance Board to ensure it remains clear and continues to reflect the law and best practice. It was last reviewed in hterm=care%20record%20guarantee Page 8

9 3.12 Legitimate Relationships A legitimate relationship (LR) is an electronic record stored on the Spine. It details the care relationship between a patient and a healthcare professional (or group of healthcare professionals). It is used to restrict access so only the healthcare professionals involved in the patient s care can access clinical information. searchterm=legitimate%20relationships In order to determine if a legitimate relationship exists, the healthcare professional must first uniquely identify the patient. This is done by tracing the patient s demographic record on the Personal Demographics Service Self Claimed Legitimate Relationship Report A Self Claimed Legitimate Relationship is when a patient is on your team s caseload and you have either been assigned this client for care or they are open to the team for treatment, whereby you have a legitimate reason to access the clients record. You will see this screen when accessing a patient who you do not have a relationship with but after entering a reason and comment if applicable and saving, this screen won t appear again PALS (Patient Advice and Liaison Services) The Trust has a PALS service which is also known as the Listen Service. This service is accessible to our service user group and the staff are approachable, efficient, confidential and professional when dealing with concerns and complaints. Leaflets, posters and other publications about PALS / Listen should be readily available on all Trust sites, giving details of the service and how to make contact with it. Staff should support service users to contact the PALS coordinator about any concerns about their data being stored on RiO Audit Trail The Audit Trail function within RiO can be used for tracking activity within a patient s case record if there is a suspicion of activity which is not appropriate or for ad-hoc internal audits. This function will primarily be carried out by the Health Records Manager. > Audit Trail Page 9

10 3.16 Caldicott Guardian A Caldicott Guardian is a senior person responsible for protecting the confidentiality of patient and service user information and enabling appropriate information-sharing Information Governance The Information Governance Assurance Framework for health and social care is formed by those elements of law and policy from which applicable information governance standards are derived, and the activities and roles which individually and collectively ensure that these standards are clearly defined and met More information can be obtained from the Connecting for Health website rchterm=information%20governance or by contacting the Trust s governance managers: 3.18 Guidance for Temporary Staff Temporary staff will not have access to RiO unless it is planned they will be in position for more than three months. Temporary staff will be issued with their own Smart Card and under no circumstances should they use anybody else s When the temporary staff member leaves, then the line manager MUST ensure they RiO Back office, via OHIS, to get the RiO account disabled. Page 10

11 Section 4 The Client Record 4.1 PDS (Personal Demographics Service) The PDS (also referred to as The Spine) is an essential element of the NHS Care Records Service (NCRS) which underpins the creation of an electronic care record for every registered NHS patient in England. Each person s care record is comprises of both demographic information, (such as name, address, date of birth and NHS Number) and medical information. The PDS is the national electronic database of NHS patient demographic details. It will enable a patient to be readily identified by healthcare professionals and associated, quickly and accurately, with their correct medical details. RiO is linked to The Spine and all patient demographic information is pulled from the Spine into our Trust version of RiO. This then means we hold the same information as GPs, acute Trusts etc 4.2 Searching and Registering 99.9% of patients have an NHS Number and are registered on the Spine. Most staff should therefore never need to register a new patient in RiO and sync the information to the Spine. Duplicating patients is a very serious issue so you MUST carry out multiple searches, using various combinations of the recommended search strings e.g. Name, D.O.B. Address etc If after doing multiple searches, you are unable to find a patient on The Spine DO NOT CREATE A NEW PATIENT ON PDS (NATIONAL SPINE) CONTACT OHIS service.desk@ohis.nhs.uk 4.3 Unable to Locate a Client If staff are unable to find a patient on the Spine they should abandon registration, keep paper details and contact OHIS Support on Tel: or service.desk@ohis.nhs.uk so that further investigations can be carried out before the patient is registered with a new NHS number. They will notify you of the patients RiO number and whether they have been able to locate the patient on The Spine or if they have had to make a new registration on RiO. Please keep patient information safe so that a referral to your service can be made. Local Search Simple National Advanced National Contact: OHIS Service.desk@ohis.nhs.uk 4.4 Duplicate records If a duplicate record is discovered, contact OHIS Support on Tel: or service.desk@ohis.nhs.uk with details of both registrations so that appropriate action can be taken. Page 11

12 4.5 Synchronisation There is specific information on registration of patient demographic details (PDS) and how you synchronise local and national information in the guidelines handed out by training. Synchronisation is used for the following reasons: Used to identify and resolve discrepancies between the information held in RiO and the information held on the national records (the Spine) GP details cannot be changed and they must be the same as national records. This is recorded on the national records centrally when the client registers with the GP. It is extremely important that these guidelines are followed at all times. Please remember to synchronise ALL records when you are prompted to do so leaving records unsynchronised may result in the data on RiO being inaccurate. 4.6 Ethnicity When synchronising from NCRS National Data to Local Data the ethnicity will not be populated, you have to select the Client s Ethnicity before saving the details, as this is a mandatory field. If the client s ethnicity has not been established at the time of registration, Not Known (Not Requested) or Not Known (Unable to Request) should be selected from the drop down box and the information updated within one week of the first assessment. If, at this time, the client does not want to specify their ethnicity, this should then be recorded as Not stated (client refused) or Not Stated (Client unable to choose). Regular reports will be run from RiO on ethnicity data to ensure that the Trust is complying with national requirements. 4.7 Other Demographic Elements Use the links at the bottom of the page to go to that part of the demographic information. Here you can also sort out any mismatch of information. Icons (What they Mean) Information is held locally and nationally the information matches. Information is held locally and nationally the information does not match. Information is held nationally no information is currently held locally. Information is held locally no information is currently held nationally. Information is held locally and an update to the national record has been requested. Historical records. Page 12

13 4.8 S Flagging hiding all patient data for extremely sensitive cases RiO has the facility that patients in extreme circumstances can apply to have their demographic information completely hidden and not available on the spine. They need to be informed that they have to apply to their GP who will action the request. This will result in all demographic data being hidden on RiO. Staff should encourage patients to go to their GP if they feel that the patient is at risk. This is expected to be only used in a minority of cases, for example clients receiving Sex Offender Treatment. This carries the risk that important information and health checks may be missed and backup processes should be in place to ensure that these clients are not missed from scheduling. All access to progress notes of patients with sensitive records will be audited regularly. 4.9 New NHS Number Process and Report on creating a new NHS number This function is not to be carried out within the Trust Clients need to register with a GP who will perform the process of creating a new NHS number 4.10 Patient Identifiers There several unique identifiers for each patient that can be used: NHS Number as unique identifier When searching for a client within RiO, it is best practice to use the NHS Number as the unique Identifier. All clients should have a registered GP which means they will have an NHS Number, if you are unable to locate a client then contact the local back office via OHIS, service.desk@ohis.nhs.uk or RiO Number When entering a client on RiO the system will generate a unique number for that person, known as the CLIENT ID Alternative Identifier eg SWIFT number Within RiO on Registration of a client you can put other Identifier s although NHS Number is the preferred method for searching for a client Local Records Save to Local (This facility is only available to the HEALTH RECORDS MANAGER) All clients should be encouraged to give their accurate demographic information and should be reassured that this will be stored safely and only accessible by people with appropriate access rights. However, in limited circumstances where staff are not confident that the information given is correct, then you need to contact the HEALTH RECORDS MANAGER for a local record to be created Death Process informal/formal If notification is received regarding a client s death, these should be referred to the HEALTH RECORDS MANAGER. Notification can come in different forms: GP letter Family Third Party or other professional bodies Page 13

14 In all cases the HEALTH RECORDS MANAGER needs to be informed so the record in RiO can be updated and also any appointments associated with the client are cancelled after verification from the Spine that the client s death has been recorded, thus to save an error made due to incorrect information being provided Logical Delete If you search for a client on RiO and there is a notification that a patient has been deleted from the Spine, then the HEALTH RECORDS MANAGER has to create a new record and locally transfer and delete all the details within RiO. This is a long process and can take up to a week to perform Consent to Share Demographic Information In version 5.4 of RiO the consent button indicates patients have agreed to their demographic information being shared on the Spine and this may ONLY be inputted by a GP. It is imperative that staff continue to discuss with clients the need to share clinical information with other necessary professionals, using the Trust leaflet. It is taken as explicit that staff have discussed this with clients. Staff will only enter details in additional personal information if clients refuse. I f staff note a YES by additional personal information they should check the information held there. The national consent icon Red Yellow Green Consent Withheld Consent not been set (implied consent) Consent has been given 4.15 Entering mobility and communication issues When registering clients who use mobility aids or with communication difficulties (e.g. vision or hearing) for the first time, clinicians are required to complete the screen entitled Additional Personal Information under the Client Details icon to record relevant information. This screen can also be used to record equipment subsequently issued to the client. On the Case record, next to the heading Additional Personal Information, will appear the word Yes to indicate that information has been entered for this client. It is recommended that clinicians view this screen prior to treating the client by following the links as detailed above and clicking on the latest entry. If the clinician subsequently finds that the details have changed, the record should be updated Entering preferred place of care Where a preferred place of care has been established all services should record this under additional personal information Entering interpreter requirements The Interpreter required box should only be ticked if an Interpreter is required to be booked by the Trust via the Interpreting Service. In this case, the native language must be selected from the drop down list. Page 14

15 Section 5 Inpatient Management 5.1 Bed (Examples) 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) Page 15

16 Section 6 Activity Data 6.1 Referral Source Below is the list of referral sources that can be selected from. Select the closest description of where the referral has come from. If the referral has come from another HCP within Ridgeway always record the referral as Internal Referral. Accident and Emergency Department (including Minor Injuries Units and Walk In) Allied Health Professional Carer Community Health Services CONSULTANTS, other than in an Accident and Emergency Department Courts Family/Friend/Neighbor General Hospital (ward) GENERAL MEDICAL PRACTITIONER Internal Referral Local Authority Social Services Not Known Other Police Prison Services Probation Services Self Specialist Nurse (Secondary Care) 6.2 Referral Reasons Below is the list of referral reasons that can be selected. It is anticipated that most referrals will fall under the category of Assessment Assessment Mental Health Act Assessment Second Opinion Treatment 6.3 Referral Urgency Record using the following time scales as a guide Activity Urgent Non-Urgent Description Within 1 week Within 1 month 6.4 Inappropriate Referrals If an internal referral is rejected because it is inappropriate, the client should be discharged from the service and a letter or generated to the referrer saying that the referral is not being accepted and why. If an external referral is rejected, staff should follow their service specific guidelines or current procedures. All inappropriate referrals should be registered, referred to the service and discharged with inappropriate referral as the discharge code as this will allow accurate monitoring and audit of the levels of inappropriate referrals by service. 6.5 Registration of urgent referrals Services need to be aware that if they need to see the patient on the day they are referred to the service they should NOT use the today/calendar box as the system will default to the time that the patient is registered and will not allow the patient to be given an appointment in the Page 16

17 diary before the registration time. When referring the patient, use the free text box next to the today/calendar box entering date and then the earliest time available in the standard diary sheet e.g This will then allow any time slot of the working day to be accessed on the diary sheet. 6.6 Eligibility for Treatment/non eligibility When a patient is referred for an eligibility assessment, the assigned HCP should create a referral as usual and record in the diary that this is as New Patient Assessment 6.7 Episode of Care This is the spell of time from referral to discharge 6.8 Referral to Assessment Time This is measured from the information in HCPs diaries a First Appointment should be recorded to stop the clock counting. All referrals should be seen within agreed time scales for the county you work within usually 28 days 6.9 Assessment to Treatment Time This is also measured by the information recorded in HCPs diaries. This time should not exceed 13 weeks 6.10 Contacts A contact should be recorded each time there is an appointment with a Client or his/her Proxy. All telephone, face to face and contact lasting more than 15 minutes in total should be entered in the RiO diary to be counted as a contact. Report writing does not count as a contact. Page 17

18 Section 7 Recording Information in RiO 7.1 Referral Buckets RiO is configured using the terminology Buckets. When receiving a referral into a Multi Disciplinary Team it can be assigned to an individual s caseload or a team s caseload, (see Section 9 - User Guide for details of how to do this) See Appendix E for list of Buckets 7.2 Student notes Students on long or destination placements who have had training and have access to RiO may write in the progress notes, which will then be validated by their mentor. Other students may write up notes in a word document format, which can be discussed with their mentor who can then cut and paste the information into the progress notes and validate them rd party information Tick the relevant box at the foot of the progress notes screen when information entered has been supplied by a third party, e.g. a GP, Social Services or a relative. The content of the third party information should be clearly identified in the Progress Note. 7.4 Entering information on others behalf. In exceptional circumstances (e.g. when an event occurs on a domiciliary visit at the end of the day where a clinician will not be able to input Rio for a few days,) an instruction may be given to another member of staff by phone, or letter, according to their access level, to enter dictated information into progress notes. The originator should be changed to that of the person dictating the entry. The entry must then be validated at the earliest opportunity. 7.5 Disclosing patient information Requests under the Freedom of Information regulations must be dealt with through the Trust s agreed process to ensure that this information is not accidentally disclosed. 7.6 Validation Electronically validating an entry in the patient record is equivalent of signing an entry in the paper notes. All HCP s are able to validate their own progress notes, if you are not then your manager will validate them for you. 7.7 Using HCP diaries The HCP (Health Care Professional) diary can appear as the home page for a clinician entering RiO. It will be the responsibility of each clinician to maintain and update their own diary. All clinicians will be expected to treat their RiO diary as their primary source for booking work activities as it is readily available to share with the team. Paper diaries / Outlook Calendars should be synchronised as often as possible with RiO diaries. 7.8 Recording Appointment Outcomes The timely and efficient Outcoming of every appointment by the clinician is required to ensure there is a record of the treatment given and to select an outcome (e.g. attended follow up appointment). It is important that staff enter activity as part of this process to provide essential information on service activity. Page 18

19 7.9 Outcome Codes When the outcome code refers to Plan ie attended/seen change of plan it is referring to a care plan or treatment plan Add to inpatient waiting lists Admitted Arrived late not seen Arrived late seen Attended/Seen change of plan Attended/Seen discharge Attended/Seen follow up appointment Attended/Seen no change to plan Attended/Seen referred for admission DNA/Not Seen change of plan DNA/Not Seen follow up appointment DNA/Not Seen no change to plan Failed Visit RTT First appointment (DNA) RTT First appointment (treatment given) RTT First appointment (treatment NOT given) RTT Subsequent appointment DNA Telephone contact change to plan Telephone contact discharge Telephone contact follow up appointment Telephone contact MHA assessment Telephone contact no change to plan Telephone contact no contact made Telephone contact Referred to admission Visit achieved This will be counted as a client DNA This option can be used when discharging a client This option should be used if you have tried to visit a client at home RTT stand for referral to treatment time This is a national target and these outcomes should be used when outcoming first appointments Page 19

20 7.10 Non client related activity This function in RiO is used for recording non-client activity, e.g.. meetings, training events, leave and study leave. To record this you click in the middle of the time of event and complete the details Travel Time To record Travel time within RiO, you need to enter it as Other Activity and select the relevant Action Code Notifications These are used to alert you that something needs to be done, e.g.. book transportation for a client attending an appointment. Use notification Icon, link at bottom of page or Appointments Icon Notifications Notifications indicator To add a notification, click add item complete the field and save. If you click on the message body this will take you to the relevant section of RiO, so you can take action on that item, if you select the client name it will take you to the case record. If you arrange transportation in advance of an appointment, RiO will send you an automatic notification to arrange transport for that client Re-direct Notification You can redirect a notification to another HCP or user, by selecting the notification and clicking redirect Clinics The clinic functionality within RiO is not currently being used. Page 20

21 7.15 Discharge reasons Clients may be discharged for a number of reasons: Achieved Outcome Admitted to hospital Assessment completed Client Died Did Not Attend Entered in Error Inappropriate Referral Moved Out of Area No appropriate treatment available Other Patient Requested Referred to Other Specialty Service No Longer Available Treated Completed Treatment completed drug free Page 21

22 Section 8 Death of a Client 8.1 Recording a death The recording of a client death will be a HEALTH RECORDS MANAGER ROLE ONLY. Staff should let the Health Records Manager know of a death as soon as possible. After verification of the Client death, the Health Records Manager will ensure that all referrals are closed and that appointments are cancelled. This will ensure that caseloads remain accurate. Until the death is confirmed on the national spine, an informal death is shown as a black triangle against the Client s name. When the death is confirmed nationally, this changes to a black circle. 8.2 Notifications of death The Health Records Manager will notify all services affected by Reversing a death A death recorded in error can be reversed while still recording that day s contacts. If it is noted at a later stage that the death was in error and new information needs to be entered on RiO then this cannot be done until the death has been reversed by the HEALTH RECORDS MANAGER ONLY. Services should notify Health Records Manager if information is gained that a patient s death has been recorded in error. Existing referrals will be reinstated but this will not reinstate outstanding appointments. Therefore appointments will need to be reinstated at a service level. Page 22

23 Section 9 Problems with RiO 9.1 Local Back Office All problems with RiO should be directed to OHIS ( or Service.desk@ohis.nhs.uk) in the first instance. OHIS will then direct the query to the Ridgeway RiO Local Back Office Team as appropriate 9.2 Operation Support Hours The support of RiO by Ridgeway Partnership and the partner organisations described in Figure 1 will be within normal working hours (09:00 to 17:00), Monday to Friday (excluding Bank Holidays. 9.3 Incident Process Flow OHIS provides the first point of contact for all RiO incidents that staff working for Ridgeway Partnership encounter. Figure 1 shows the pathway that an incident should follow. In the event that a user experiences any problem with RiO, they are to report it to the OHIS Helpdesk either by telephone or service.desk@ohis.nhs.uk The OHIS helpdesk will then analyse the issue and assign it accordingly, be it within its own organisational hierarchy or to a supplier organisation. Page 23

24 9.4 Ridgeway RiO Local Back Office Ridgeway have established a local back office function which will adopt the support of 3 keys areas of RiO Support. Structure Application Support/Health Records Management This function is being fulfilled by the Health Records Manager, System Administration This function is being fulfilled by the Information Analyst in the ICT department/information and Quality Directorate. RA (Registration Authority or smartcards) This function is being fulfilled by the RA Department/HR Directorate. Please see Figure below for a breakdown of responsibilities. Page 24

25 9.5 Ridgeway LBO RiO Governance Structure The Local Back Office (LBO) is part of a three layered support model that assures end users are supported, both in terms of Incident Management, but also in terms of assuring that recording of patient information is done in a standardised and consistent manner. This enables the increased quality of patient care through better information as well as more granular data that support business performance metrics. It is the responsibility of the Trust Management Executive to ensure this framework is managed and adhered to. 9.6 Change requests Amend User Permissions Please log a call with OHIS Add New Team Please log a call with OHIS Create Additional Referral Bucket Please raise with your Champion User or log a call with OHIS The RiO Implementation Group is a monthly meeting held to discuss any issues or changes that have been arisen during the month. Page 25

26 Appendix A Glossary of Terms Abbreviation Authority B Code BT CDS CFH Collendra CPA CRS DCW ESR ICT IG IG Toolkit Logical Delete LBO OHIS PAS PCT PDS R Code RA RBAC SCR Spine Synching TNA XFB Full Name The Department of Health, ultimately The Secretary of State for Health. (NHS Connecting for Health is also referred to as the Authority.) Activity Code which is associated to a specific application function. British Telecommunications plc Commissioning Data Set Connecting for Health - Contract and Delivery agency for NHS National Programme for IT Current interface to manage users who are having issues with a Smartcard Care Programme Approach Care Records Solution Data Collection Workbook - Spreadsheets which hold trust team information Electronic Staff Record - HR System Information And Communication Technology (= IT) Information Governance - Process that describes best practice for maintaining integrity of data. Mechanism for recording the above. Process by which information is deleted from front end of application but it stiff available for restoration. Local Back Office provide support for Ridgeway s RiO Database. Oxfordshire Health Informatics Service - IT Support company. Patient Administration System Primary Care Trust Patient Demographic Service - Database holding all UK Patients demographic information Parent (Role) Code for a Role which can contain B codes Registration Authority Role Based Access Control - security config that determines what a user can see/do when they log in to an application. Made up of R and B Code Summary Care Record. Holds full information for each patient on the spine and is planned to hold clinical information in the future Core NHS Network which connects spine enabled applications (also refers to PDS dependent on context) Process by which a user synchronises a local record with the corresponding PDS record. Training Needs Analysis File Transfer mechanism from RiO to Trust Page 26

27 Appendix B - Registration Fields withinin RiO The following table shows the status of demographic information which the Trust has decided should be collected in relation to clients FIELDS Client ID NHS Number NNN Status This person is a client This person is a carer This person is a client and a carer Title, Surname, First name National Insurance Number Marital status Gender Date of Birth Estimated date of birth (tick box) Ethnicity Nationality Religion Occupation Interpreter required First language (if not English) Current school Client s Current Address Post Code Health Authority of Client Address Client Address Address from date Comment Daytime Phone number Evening Phone number Date registered Practice Name Practice address Practice Phone Health Authority of GP practice CPA GP practice Date registered with GP Carer STATUS System generated Mandatory System generated Mandatory choose as appropriate Mandatory Do not collect Enter if know Mandatory Mandatory Where appropriate Mandatory Only if pertinent to person's care Only if pertinent to person's care Only if pertinent to person's care Mandatory if Interpreter will be booked by Trust via Interpreting Service Mandatory if Interpreter required, as above N/A Mandatory Mandatory System generated System generated Enter today s date if not known Desirable to record relevant information about address, location etc Desirable Desirable Do not collect enter today s date if not known Mandatory GPs name System generated System generated System generated System generated Enter today s date if not known Only if appropriate Page 27

28 Appendix C RiO SOP Change Request Form User Guidance All requests for changing information on the trust wide and Service specific Standard Operating Procedures (SOP) must be initiated using this form. The first 6 lines should be completed and the requesting service lead should sign/print in the box following this and send to the RiO Operational Lead for consideration. All changes will be reviewed by the RIO change request panel, consisting of the RiO Operational Lead and Clinical Safety Officer, to ensure we maintain consistency across the Trust of how the RIO system is used. Once the changes have been agreed the form will be completed and the necessary changes will be made to the master copy of the SOP which can be found on the intranet via the RIO home page. If the changes are not agreed the panel chair will feedback the reasons to the service for further discussion and consideration. A log will be kept of the various versions of each SOP and the dates they were in use, for audit and complaints purposes SERVICE Current version of SOP RIO SOP CHANGE REQUEST FORM Request made by Date Change Requested Reason Signature Discussed (with whom) Agreed (by whom) Changes made to database Date YES/NO By New version no Signed Page 28

29 Appendix D The Care Record RiO is the Primary Care Record for all Clients of Ridgeway Partnership (Oxfordshire Learning Disability NHS Trust). The paper record i.e. the integrated clinical record, is the secondary care record and will contain: a resume of key clinical factors from within RiO (as set out in A below) any paper copies of documents not supported by RiO (as set out in B below) If you are keeping a paper record or any kind you must ensure the HEALTH RECORDS MANAGERS knows of it s whereabouts. A Demographic information 1. Demographics i.e. name, address, dob, NHS Number, GP, etc. IMPORTANT All service users must have a Care Plan within RiO. 2. Consent to share information signed by client. This is not printable from RiO, current Trust documentation should be used (a consent to share information form can be found at the back of the Trust s Information Sharing Policy). B paper documents not currently supported within RiO 3. Mental Health Act documentation/ other legal documentation e.g.. data protection subject access requests. IMPORTANT These documents must be signposted within the Care Plan and the progress notes in RiO, as to their location. 4. Investigations/ test results i.e. blood tests, X- rays. 5. ECT consent form and treatment pack 6. Correspondence e.g.. from housing, benefits agency, third party e.g. GP, relatives etc From 1 st January 2012, each client s existing paper records will be closed and used for reference only until ready for archive. No new information should be added to these records, except information that cannot be stored within RiO (eg letters from GPs). Staff should be recording as little on the paper notes as possible now, in preparation for this transition. NHS Number Project As the Trust is now using RiO as it s primary health record there is an NHS number on all Clients records. The Trust is therefore fully compliant with the guidance of the National NHS Number Project. All paper records which are held must have a front sheet printed from RiO which includes full patient demographic information. This will have the patient s NHS number on it, so all paper records will also be compliant. Page 29

30 Appendix E Team Buckets Team Name Oxon Inpatient New Referral Oxon Inpatient Ongoing Care Oxon Inpatient Waiting List Oxon Inpatient OT Oxon Forensic New Referral Oxon Forensic Ongoing Care Oxon Forensic Waiting List Oxon Forensic OT SCSCG ECRs Bucks Inpatient New Referral Bucks Inpatient Ongoing Care Bucks Inpatient Waiting List Evergreen Therapy Suite Oxon LDT S&LT Generic Oxon LDT Dietetics Generic Oxon LDT CHC Generic Oxon North LDT New Referral Oxon North LDT Ongoing Care Oxon North LDT Eligibility Oxon North LDT Physio Oxon North LDT OT Oxon North LDT Psychiatry Oxon North LDT Psychology Oxon North LDT Nursing Oxon North LDT Care Managers Oxon North LDT Social Workers Oxon City LDT New Referral Oxon City LDT Ongoing Care Oxon City LDT Eligibility Oxon City LDT Physio Oxon City LDT OT Oxon City LDT Psychiatry Oxon City LDT Psychology Oxon City LDT Nursing Oxon City LDT Care Managers Oxon City LDT Social Work Oxon South LDT New Referral Oxon South LDT Ongoing Care Oxon South LDT Eligibility Oxon South LDT Physio Oxon South LDT OT Oxon South LDT Psychiatry Oxon South LDT Psychology Oxon South LDT Nursing Oxon South LDT Care Managers Oxon South LDT Social Workers Page 30

31 Bucks LDT New Referral generic Bucks LDT Ongoing Care generic Bucks North LDT OT Bucks North LDT Psychiatry Bucks North LDT Psychology Bucks North LDT Physio Bucks North LDT Nursing Bucks South LDT OT Bucks South LDT Psychiatry Bucks South LDT Psychology Bucks South LDT Physio Bucks South LDT Nursing Bucks LDT SLT Generic Wilts Inpatient New Referral Wilts Inpatient Ongoing Care Wilts Inpatient Waiting List Wilts LDT New Referral Wilts LDT- Ongoing Care Swindon LDT- Psychiatry Wilts LDT Psychiatry Swindon LDT Psychology Wilts LDT Psychology Swindon LDT New Referral Swindon LDT Ongoing Care Page 31

32 Appendix F List of RA Agents Amber Hodges Jayne Garrett Rachel McCarthy Sue Keating Phyllis Hoskings Sandra Cox Valerie Johnston Valeria Irving Andrew Walker Sally Whittington Marlyn Hillier Anne Lewis Liz Szczerbiak Theresa Hastings Lisa Griffiths Jan Wise Sue Adlam Kathy Drewitt Slade House Slade House] Slade House Slade House Slade House & Haleacre, Amersham Slade House Knight s Court, Oxford Oxford LDTs Foxcombe Court, Abingdon Redlands Centre, Banbury Postern House Postern House Easton Street, High Wycombe & Haleacre, Amersham Midshires, Aylesbury Easton Street, High Wycombe Midshires, Aylesbury Chatsworth House, Swindon Chatsworth House, Swindon Page 32

33 Appendix G Relevant Roles & Responsibilities PALS / Listen Coordinator Clare Winton Clare.winton@ridgeway.nhs.uk Caldicott Guardian Dr Matthew Stephenson Matthew.stephenson@ridgeway.nhs.uk Information Governance Manager Health Records Manager Sarah Watkins Jayne Garrett Sarah.watkins@ridgeway.nhs.uk Jayne.garrett@ridgeway.nhs.uk RiO Executive Lead Dr Matthew Stephenson Matthew.stephenson@ridgeway.nhs.uk RiO Operational Lead Amber Hodges Amber.hodges@ridgeway.nhs.uk Clinical Safety Officer Dr Subimal Banerjee Subimal.banerjee@ridgeway.nhs.uk Mental Health Act Administrator Sandra Cox Sandra.cox@ridgeway.nhs.uk Page 33