Standard Operating Procedure User Guide Version 1.4 September 2011 Page 1
Contents SECTION 1 - INTRODUCTION... 6 SECTION 2 - GENERAL INFORMATION... 7 2.1 Mandatory Fields... 7 2.2 Your Home Page... 7 2.3 Information Bar... 8 2.4 Case Record... 8 2.5 NHS Number as unique identifier... 8 2.6 Synchronisation... 8 2.7 Entering Dates/Times... 8 2.8 Effective Dates... 9 2.9 Spell Checker... 9 2.10 Problems with RiO... 9 SECTION 3 - CLIENT DEMOGRAPHICS... 10 3.1 General Principles... 10 3.2 The Procedure... 10 3.2.1 Registering a Client on RiO... 10 3.2.2 Updating Client Demographic Information... 11 3.2.3 Adding / Amending Client Names... 11 3.2.4 Adding / Amending Client Personal Contacts... 11 3.2.5 Client Professional Contacts... 12 3.2.6 Adding / Amending Communication Details... 12 3.2.7 Adding / Amending Addresses... 12 3.2.8 Adding GP History... 12 3.2.9 Client Alternative IDs... 13 3.2.10 Linking information that has been recorded more than once and keeping Client Demographics up to date... 13 3.2.11 Role as a Carer... 13 3.2.12 Nearest Relative... 13 3.2.13 Recording Additional Personal Information... 14 3.2.14 Client Demographic Front Sheet... 14 3.2.15 Death of a Client... 14 SECTION 4 - RECORDING CLINICAL INFORMATION... 15 4.1 General Principles... 15 4.2 The Procedure... 15 4.2.1 Progress Notes... 15 4.2.2 Adding a Progress Note... 15 4.2.3 Updating an un-validated Progress Note... 16 4.2.4 Progress Note entered in Error... 16 4.2.5 Printing Progress Notes... 16 4.2.6 Viewing Significant Events... 17 4.2.7 Uploading Documentation... 17 4.2.8 Removing uploaded documents... 17 4.2.9 Viewing uploaded document... 17 4.2.11 Assessment Forms... 18 4.2.12 Viewing / Printing the Core Assessment... 19 Page 2
SECTION 5 - CARE PLANS... 20 5.1 The Principles... 20 5.2 The Process... 20 5.3 The Procedure... 21 5.3.1 Care Plans... 21 5.3.2 Editing a Problem/Need or Intervention... 21 5.3.3 Closing a Problem/Need or Intervention... 21 5.3.4 Sort the Care Plan into Order... 22 5.3.5 Enter Care Plan Contact Details... 22 5.3.6 Enter Care Plan Distribution Details... 22 5.3.7 Printing a Care Plan... 22 5.3.8 Printing a Full Care Plan Including CPA Review Details... 22 5.3.9 Printing a Point in Time Care Plan... 22 5.3.10 Printing an Inpatient Care Plan... 23 5.3.11 Printing a Point in Time Inpatient Care Plan... 23 SECTION 6 - RISK INFORMATION... 24 6.1 The Principles... 24 6.2 The Process... 24 6.3 The Procedure... 24 6.3.1 Alerts... 24 6.3.2 Adding an Alert & Maintaining Alerts... 25 6.3.3 Risk Incidents... 25 6.3.4 Risk Assessments... 25 6.3.5 Risk Management Plans... 26 6.3.6 View / Print a Risk Summary... 26 6.3.8 HCR-20... 26 SECTION 7 - CARE PROGRAMME APPROACH (CPA)... 27 7.1 General Principles... 27 7.2 The Process... 27 7.3 The Procedure... 28 7.3.1 Record a CPA Episode... 28 7.3.2 Record all Contacts... 28 7.3.3 Complete Core Assessments... 29 7.3.4 Book CPA Meeting... 30 7.3.5 Record Outcome of Review Meeting... 30 7.3.6 Validate the CPA Review... 31 7.4 Additional Information... 31 7.4.1 To change the CPA Care Coordinator... 31 SECTION 8 - INPATIENT MANAGEMENT... 32 8.1 General principles... 32 8.2 The Process... 32 Page 3
8.3 The Procedure... 33 8.3.1 Creating a New Referral... 33 8.3.2 Transferring a Referral to a Waiting List... 33 8.3.3 Discharging a Referral... 33 8.3.4 Admitting a patient into a bed... 33 8.3.5 Recording a Ward Attender... 34 8.3.6 To Discharge a Client... 34 8.3.7 Planning an event... 34 8.3.8 Authorising a Planned Event... 34 8.3.9 Recording a Planned Event... 35 8.3.10 Recording a Patient as a Delayed Discharge... 35 8.3.11 Record a Patient as on Leave... 35 8.3.12 Record a Patient as AWOL... 35 8.3.13 To swap patients between beds... 36 8.3.14 To move a patient to a vacant bed... 36 8.3.15 Recording a patient as Sleeping Over in another unit... 36 8.3.16 Reversing an Inpatient Admission Entered in Error... 36 8.3.17 Adding a Diagnosis (ICD-10 code)... 37 8.3.18 Confirming a Diagnosis Relating to Discharge from Inpatient Services (Finished Consultant Episode)... 37 8.3.19 To Show Confirmed Diagnoses... 37 8.3.20 Recording Reading Patient s Rights... 38 8.3.2 To View a Client s Section History... 38 SECTION 9 REFERRALS, DIARY MANAGEMENT & ACTIVITY DATA... 39 9.1 General Principles... 39 9.2 The Process... 39 9.3 The Procedure... 40 9.3.1 Creating a Referral... 40 9.3.2 Transferring a Referral... 40 9.3.3 Discharge a Referral... 40 9.3.4 Managing New Referrals... 40 9.3.5 Allocate a Referral to an HCP... 41 9.3.6 Reallocating a Client or Sharing a Client with another HCP... 41 9.3.7 Caseload Management... 41 9.3.8 Removing a Client from a Caseload... 42 9.3.9 Viewing a Printable Caseload... 42 9.3.10 Diary Management... 42 9.3.11 Adding / removing another Client to an appointment... 43 9.3.12 Adding / removing another HCP to an appointment... 43 9.3.13 Cancelling an Entire Appointment... 43 9.3.14 Outcoming an Appointment... 44 9.3.15 Booking / Cancelling non-client related Appointments... 44 9.3.16 Viewing a Printable Diary... 44 9.3.17 Viewing a Client s Diary... 44 SECTION 10 - MENTAL HEALTH ACT... 45 10.1 General Principles... 45 10.2 The Process... 45 10.3 The Procedure... 46 10.3.1 Record Section... 46 10.3.2 Renew Section... 46 Page 4
APPENDIX A - 5X5 RISK MATRIX... 47 APPENDIX B GLOSSARY OF TERMS... 48 Page 5
Section 1 - Introduction This Standard Operating Procedure (SOP) has been split into two distinct documents A User Guide, detailing the most frequently performance 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 Reference Guide 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 User Guide Page 6
Section 2 - General Information 2.1 Mandatory Fields Most screens where information is inputted into RiO will have some mandatory fields these fields are displayed in light green. If you try and save an entry without entering data in a mandatory field you will be prompted to do so before proceeding. 2.2 Your Home Page Your home page will differ depending on your role within the organisation. Below are instructions for using your homepage: No. Instruction 01 Your homepage is displayed when you log into RIO. If you are a HCP your homepage will be the diary, if you are Admin & Clerical Support then your homepage will either be team caseload or diary of manager. 02 Click on the icons on the top right of the screen to display menus of options (See below) Additional Information HCP= Health Care Professional, who comes into direct contact with clients The icons available to you will depend on your role see below. 03 If you are unsure where you are in the RiO system, click on the RiO logo in the top left of the screen to return to your home page. Client Record Appointments Inpatients MHA (Mental Health Act) Operational Reports Statutory Reports PAS Admin Reverse Function Page 7
2.3 Information Bar An information bar is displayed at the top of every screen within RiO. DO NOT use the back button icon on the Internet screen, if you wish to go back, use the blue back button in RiO, if you use the back button on the Internet screen you may exit RiO. Always click Log Off before closing the window it is important that you use the information bar consistently for various functions. 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 the lesson about logging on to RiO. Amber Hodges RHXM Log Off Your name. The system you are using either the training or the live environment. A hyperlink to log you off the system. 2.4 Case Record A case record is unique to each individual Client and becomes the Health Record. If you click wherever you see the client s name underlined in RiO, this will take you to their Case Record 2.5 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 HEALTH RECORDS MANAGER. 2.6 Synchronisation If prompted to synchronise a record, wherever possible you should do this. Leaving records unsynchronised may result in the data on RiO being inaccurate. Don t worry: it is fine to upload information to the National Spine in fact it is encouraged this is about keeping a Clients details up to date and making sure everybody has the same information! 2.7 Entering Dates/Times You can enter dates in any recognised format, e.g. 01-01-11, 01/01/2011, 01 01 11, 01 Jan 11 etc. Times all use the 24 hour clock Clicking will bring up a calendar to select the date/time from. Clicking will enter the current date/time. Page 8
2.8 Effective Dates An effective date or as of date is the date upon which something is considered to take effect. If an exact date isn t known, then you should enter the date you first became aware of the information e.g. if you don t know the exact date someone moved, enter the current day as this is the first day you became aware of the move. 2.9 Spell Checker Wherever the symbol is seen, if you click on it the free text you have added will be spell checked 2.10 Problems with RiO If you need assistance completing a task on RiO, in the first instance contact your local Champion User (for an up to date list of Champions, see the intranet) If RiO is not working properly please contact OHIS on 01865 222822. Page 9
Section 3 - Client Demographics 3.1 General Principles Demographics refers to the identifying information about a client, e.g. their name, address, date of birth, personal contacts, etc. The Registration Screen is used for entering and amending the client demographic information. It is the responsibility of ALL staff to make sure this information is completed and kept up to date. This can either be done by either changing the information as and when you know this needs to happen, or making sure that if prompted you synchronise the local record with the National Spine. 3.2 The Procedure 3.2.1 Registering a Client on RiO Click and select Registration Search for the client using the NHS number If this is not available, use the name and preferably the date of birth NB Search local records several times with as much information as you have to make sure the client isn t already registered on the system. Search National Records Click anywhere on the line with the client details. This takes you to the Synchronising screen, tick the boxes on the NCRS National Data side of the screen and then click on Page 10
3.2.2 Updating Client Demographic Information To access the Client Details Screen either: Click and select Registration Search for the client using the NHS number If this is not available, use the name and preferably the date of birth OR When in the Case Record click Full Name (ClientID) 3.2.3 Adding / Amending Client Names There is the ability to record other names for clients. This is useful if somebody likes to go by an alias eg different first name, is commonly known as something else or is using a different surname (e.g. mother s new married name etc). Names which have been formally changed (e.g. as a result of marriage) should be updated, the former name will remain as an Alias. A search for the client using either name will bring up the correct record. If you know of an alias for any client you should ensure it is entered in RiO From the Client Details Screen Click on Client Names Edit this client then Add New Name to record an additional name OR Edit (next to the information you want to change), to amend details Enter the details & If an alias is no longer relevant Edit and enter an End Date 3.2.4 Adding / Amending Client Personal Contacts This section should be used for recording ALL non-ridgeway contacts eg family, education, home support, Care Manager etc. From the Client Details Screen Click on Client Personal Contacts Edit this client then Add New Contact OR Edit (next to the information you want to change), to amend details Enter the details & Page 11
3.2.5 Client Professional Contacts DO NOT enter information under Professional Contacts. contacts under Personal Contacts Record all the Clients non-ridgeway 3.2.6 Adding / Amending Communication Details This tab is for recording other ways of contacting Clients, e.g.. fax, work number, mobile. From From the the Client Client Details Details Screen Screen Click on Communications Edit this client then Add New Communication OR Edit (next to the information you want to change), to amend details Enter the details & 3.2.7 Adding / Amending Addresses This tab is used for adding past addresses From the Client Details Screen Click on Addresses Edit this client then Add New Contact OR Edit (next to the information you want to change), to amend details Enter the details & NB - If a client changes their address details with the GP the PDS (Personal Demographics Service) will be notified, when you enter a client record there will be notification of a synchronisation change, you should try in all cases to do this change asap. 3.2.8 Adding GP History When downloading a client from the PDS (Patient Demographic Service) the clients GP History will not be brought down, only the current GP. From the Client Details Screen Click on GP History Edit this client then Add New Contact OR Edit (next to the information you want to change), to amend details Enter the details & NB: Ensure you add the Start/End date Page 12
3.2.9Client Alternative IDs There can be a number of ID s relating to a client, e.g.. NHS Number, SWIFT number (from local Social Care System), EPEX number (from old Electronic Patient Records System). The primary / unique identifier for clients within RiO is the NHS Number. From the Client Details Screen Click on Client Alternative IDs Enter details then NB the EPEX, SWIFT and TED number will display on the Client Search Screen 3.2.10 Linking information that has been recorded more than once and keeping Client Demographics up to date If, when searching for a client, you locate more than one telephone number or addresses which are similar but not identical, or have no spaces etc., these need to be linked, or closed with a start/end date. From the Client Details Screen Click on Communications Click Edit this client Click on edit and update then tick the boxes to link Then click 3.2.11 Role as a Carer Next of kin/carer s contact details should normally be recorded with as much detail as possible in RiO under contact details. However, a carer should be separately registered if: The carer also has a care need and/or The carer is receiving services from the Trust 3.2.12 Nearest Relative Nearest Relative is a legal term used in the Mental Health Act (2007) and is different to a Next of Kin. Next of kin information should be recorded in personal contacts. Nearest Relative information should only be recorded by the Mental Health Act Administrator Page 13
3.2.13 Recording Additional Personal Information As well as the client demographic information, you can also add additional information about the client for example, any distinguishing features Case Record > Client Demographics > Additional Personal Info Enter details and 3.2.14 Client Demographic Front Sheet If you still hold any paper records for a client you must print a patient demographic front sheet and include this at the front of the folder Case Record > Client Demographics > View Demographics 3.2.15 Death of a Client Only the HEALTH RECORDS MANAGER should record the death of a client on RiO. Please notify the HEALTH RECORDS MANAGER as soon as you are made aware of the death of client who is open to your team, she will then be able to confirm the relevant details and ensure that RiO and the National Spine are updated accordingly. Page 14
Section 4 - Recording Clinical Information 4.1 General Principles All clinical information must be recorded in the appropriate place on RiO. Day to day notes for all professional groups should be recorded in Progress Notes. No member of staff should be storing this information in a paper file, unless there are exceptional circumstances and this has been agreed with the Caldicott Guardian. All Notes should be entered in a timely fashion, as missing information could pose a clinical risk. Progress Notes must be validated as soon as possible after writing. Validating a Progress Note is the equivalent of countersigning it. All unqualified members of staff must have their notes validated by a qualified member of staff. Trainee Psychologists are able to validate their own notes. HCAs are not able to validate their own notes and it is the supervising HCPs responsibility to ensure that their HCAs notes are validated promptly. Unvalidated notes are displayed in purple italics All data that can be recorded on an Assessment Form should be rather than putting everything in Progress Notes Relevant clinical documentation that cannot be entered on a Form or in Progress Notes should be uploaded. This will include things like reports and letters from professionals outside of Ridgeway. There is no need to upload information that is not relevant e.g. general appointment letters. Any document that is uploaded should be a final version. It is the responsibility of each HCP to upload the information for their professional team. I.e. you should only be uploading information relevant to your profession and not information from other professions Uploaded documentation should not be circulated to Ridgeway staff, but a note included in the Progress Notes to say a relevant document has been uploaded, if others are to read the information. Where very sensitive personal information or process notes may need to be recorded for a client, it may be agreed to maintain separate progress notes in paper form. This should only be done in exceptional circumstances and should be discussed with the Caldicott Guardian before the decision is taken. A note should be entered in the progress notes on RiO to make it clear that this decision has been taken. The Health Records Manager must be informed of all such records so the location of these can be recorded 4.2 The Procedure 4.2.1 Progress Notes All clinicians are responsible for ensuring they enter progress notes following all clinical encounters. 4.2.2 Adding a Progress Note The Progress Notes are the main area for writing clinical notes. Case Record > Progress Notes Enter your note Tick all the relevant boxes as necessary Tick the Validate this note box if you are an HCP Page 15
If you are entering the note on behalf of somebody else, search the Originator. for the relevant person to change Ensure the Date and Note Type are correct. You should tick This is a significant event if you particularly need to draw others attention to the note e.g. Change of medication, follow up after discharge, important report uploaded or, Client taken into hospital. Tick the Add to Risk History box if the note contains information about a risk. Use >> to move the relevant risk(s) to the Selected area. Tick This note contains third party information if the note contains information that you have been given by another person. Current Problem Types - These are a list of all the Care Plans that are currently open. If appropriate tick the box next to the Used Type, if the note contains information relevant to a particular care plan. 4.2.3 Updating an un-validated Progress Note To update an un-validated Progress Note E.g. to add further information to the note or to Validate it. Case Record > Progress Notes Update next to relevant note Update the note as needed Tick the Validate this note box if you are an HCP 4.2.4 Progress Note entered in Error To mark a validated note as entered in error. Case Record > Progress Notes Amend next to relevant note Tick Entered in Error Tick the Validate this note box if you are an HCP 4.2.5 Printing Progress Notes Any request for access to health records should be directed to the Health Records Manager If access is agreed then the relevant notes can be printed from RiO. Case Record > Client Related Data-Views > Progress Note View Enter the required details & Page 16
4.2.6 Viewing Significant Events Significant Events are generated automatically by the system in RiO, if for example a new referral is opened, a Client is admitted into Hospital or a Care plan is opened. Significant Events can also be flagged when entering a Progress Note. Case Record > Client Related Data-Views > Significant Events The notes can be filtered by ticking the required boxes and 4.2.7 Uploading Documentation Please make sure that the document you upload is the final version as, once uploaded, a document cannot be edited. Please note that at present documents created in Microsoft Office 2010 are not compatible for upload if you use MS Office 2010 please make sure the document is saved as a 97-2003 Document. Case Record >Clinical Documentation > Document Upload for document Enter the other details (as below) File Author File names should be in the following format Client full name_ type of document _initials of author _date e.g.: JohnSmithDischargeReportTJ01012011 DO NOT leave this field blank as it will default to the person uploading the document Document Title use the following naming convention. Client name type of document e.g. JSmith Continence Assessment Please note there is only a maximum of 40 characters that can be entered in the Document Title box, so please use the description box to put further detail in. Document Type this is a predefined list, please use the most appropriate option available to you. Being accurate will make it easier to filter and find the document later Description - Enter as much detail as possible doing this will save time later. Remember it will not always be the person uploading the document who needs to view it! 4.2.8 Removing uploaded documents If you upload an incorrect document, you must ensure it is removed promptly. Only senior administrators and back office staff can remove documents. Case Record >Clinical Documentation > Document List Removal Tick the box next to the document you want to remove and Click and confirm deletion 4.2.9 Viewing uploaded document Case Record >Clinical Documentation > Document List View Select the document you want to open Page 17
4.2.10 Editable Letters Editable letters are pre-set templates that pull through key Client Demographic information on to a Word document for you to edit. Case Record >Clinical Documentation > Editable letters Select the Letter Type you want to open and This will open a fully editable Word document which can be saved and uploaded to RiO if relevant 4.2.11 Assessment Forms Assessment forms all work in the same way and are located from the Client Case Record. Case Record Locate the relevant form (see below) Click or Complete the form and For paper copies of these forms please see the Intranet. The Assessment Forms and their location are as follows: Social Inclusion Client Referrals > Referral Screening > Police Screening Request Form MCA & Information Sharing and consent > Advance Decisions and Statements > Best Interest Considerations > Capacity Assessment > Capacity Contacts > Deprivation of Liberty > Information Sharing and Consent Core Assessment > Core Assessment > Presenting Situation & Referral Outcome Decision > Mental Health History > Physical Health History > Personal & Family History > Social History / Care Management Form > Mental Health Legislation / Protection of Vulnerable Adults > Forensic & Probation History > Substance & Alcohol Use > Problematic Substance And Alcohol Use Form > Mental State Examination > Observations of Client and Family / Carer > Physical Examination > Physical Health Assessment > Physical Monitoring > Nutrition Page 18
Core Assessment > Core Assessment > Body Map Annotations > Client & Carers Understanding of Assessment > Formulation / Summary Risk Information > HCR-20 > Risk Assessment > Safeguarding Children Adult Form 1 > Safeguarding Children Adult Form 2 > Safeguarding Children Child - Form Role as Carer Information > Carer Assessment Specialist Assessments > MOHO OT Assessment > MOHOST & OCAIRS > OPHI-II > VQ and ACIS > WRI & WEIS > Occupational Self Assessment (OSA) Summary > NCDS > NCDS Form > NCDS Rating > NDTMS > NDTMS Main Capture Form > NDTMS Adult Services Modalities > NDTMS Young People Services > NDTMS TOP > Observation / Seclusion > Access to Fresh Air > Observation > Seclusion Outcome Measures > Experience of Service > HoNOS65+ (Older adult) > HoNOS-ABI > HoNOSCA > HoNOSCA-SR > HoNOS-LD > HoNOS-secure (v.2) > Paddington Complexity Scale > Strengths & Difficulties Care Planning, CPA & Review > Care Plan Contact > Care Plan Distribution > Crisis, Relapse and Contingency > Pre-Discharge Planning > MAPPA Review > Section 117 Review Information Mental Health Act > MH1 Assessment > Nearest Relative > Section 117 Eligibility > Section 132 Right 4.2.12 Viewing / Printing the Core Assessment You may want to view or print an overview of all the assessments completed under core assessment, or a point in time snapshot of the assessments completed Case Record >Core Assessment > Core Assessment Overview Or for a point in time overview Case Record >Core Assessment > Core Assessment Point in Time Enter date & Page 19
Section 5 - Care Plans 5.1 The Principles Care Plans should be clearly linked to outcomes from Assessments / Risk Assessments The Need should be clearly identified The Actions should clearly link to the Need In each action you must identify who is responsible for doing what and when Clearly identify how you are going to measure if actions are successful Ensure the care plan has a start date entered. Record when the care plan will be reviewed and who is responsible for ensuring this happens Clearly document in Progress Notes when reviews have taken place and if anything has changed Ensure Care Plans are kept up to date and closed if no longer in use Care plans should be completed on RiO for all treatment / care plans that are in place and all Risk management plans that are used. All professions should complete Care Plans. Record whether the Client has been involved in developing the care plan and whether they agree with it or not. 5.2 The Process Enter Problem / Need Select problem category from dropdown Enter the specific details of the problem or need which has been identified Enter New Goal / Intervention Enter interventions / actions and Outcomes Use a separate line for each intervention Record start date Ensure that if completing a care plan associated with risk that 5x5 score is included Complete Care Plan Contact / Distribution Complete contact details if the care plan is to be given to the client Complete the distribution list as appropriate Close Care Plan Update the care plan as necessary If the care plan (or particular intervention) is no longer required -close the care plan or enter an end date for the intervention Page 20
5.3 The Procedure 5.3.1 Care Plans Case Record >Care Planning, CPA and Reviews > Care Planning Click Select Problem/Need Type from drop down, enter a description of the Problem/need and Care Planning (to return to care plans) Click on the Problem/Need just entered (this will highlight it in pink) Click Enter details & Repeat this for further interventions, when finished click Care Planning (to return to care plans) Intervention Type: - this doesn t need to be populated Intervention / Actions and Frequency enter full details of the planned intervention. If completing a Risk Care Plan the first line should have the current level of risk prior to intervention in line with the 5x5 risk matrix eg: Current level of Risk prior to intervention = 3x4 (Orange) Anticipated Outcome and Clients View enter full details of the expected outcome if the intervention is successful. If completing a Risk Care Plan the first line should have the residual risk in line with the 5x5 matrix included eg: Residual Risk Rating = 2x2 (yellow) 5.3.2 Editing a Problem/Need or Intervention Case Record >Care Planning, CPA and Reviews > Care Planning Click on the Problem/Need or Goal/Intervention to edit NB you may need to click to view the interventions Click Make the required changes Care Planning (to return to care plans) 5.3.3 Closing a Problem/Need or Intervention Case Record >Care Planning, CPA and Reviews > Care Planning Click on the Problem/Need or Goal/Intervention to edit NB you may need to click to view the interventions Click Select outcome reason and enter a comment Page 21
5.3.4 Sort the Care Plan into Order The Problems on a Care Plan can be sorted. The interventions under a specific problem cannot be ordered. Case Record >Care Planning, CPA and Reviews > Care Planning Click on the Problem to move and use the arrows to move it up or down 5.3.5 Enter Care Plan Contact Details Case Record >Care Planning, CPA and Reviews > Careplan Contact Enter details & 5.3.6 Enter Care Plan Distribution Details Case Record >Care Planning, CPA and Reviews > Careplan Distribution Enter details & 5.3.7 Printing a Care Plan There are a number of different ways to print a care plan, each give you slightly different details in a different layout. Choose the most appropriate care plan depending on the need of it. 5.3.8 Printing a Full Care Plan Including CPA Review Details If printing a Care Plan for distribution following a CPA you must use this way of printing. Case Record >Care Planning, CPA and Reviews > Care Planning Click Printable Care Plan This opens up a fully editable Word Document 5.3.9 Printing a Point in Time Care Plan Case Record >Client Related Data-Views > Care Plan Overview Point in Time Enter a date & Page 22
5.3.10 Printing an Inpatient Care Plan Case Record >Client Related Data-Views > Inpatient Care Plan Enter a date & 5.3.11 Printing a Point in Time Inpatient Care Plan Case Record >Client Related Data-Views > Inpatient Care Plan Point in Time Enter a date & Page 23
Section 6 - Risk Information 6.1 The Principles Alerts should be completed for all Clients with a physical health condition that staff may need to know about, and if the Client is identified as being in an at risk group e.g. at risk in hot weather. Risk information should be completed for all Clients where a risk is identified. All Clients on CPA should have a Risk Assessment completed. Care Plans on RiO form the Risk Management Plan and must be completed if a risk is identified. All Risk Care Plans must reference risk prior to intervention and residual risk score according to the 5x5 matrix. Both scores must be included on the Risk Care Plan. If additional risk assessments / specialist risk assessments are completed they should be referenced in the RiO Risk Assessment and a copy uploaded or summarised in RiO as appropriate. See Appendix A 5x5 Risk Matrix. 6.2 The Process Enter Alerts & Flag Risk Enter & Manage Alerts Flag risks via Progress Notes Enter historical Risk information under Risk Incidents Complete Risk Assessment Complete the Risk Assessment Complete Risk Care Plans Ensure the pre-intervention & residual scores/ratings are recorded using the 5x5 matrix as reference 6.3 The Procedure 6.3.1 Alerts HCPs are encouraged to use and maintain Alerts on the client s Case Record to flag up the following issues: Allergy Asthma Cardio-vascular risk Diabetes Epilepsy Other Other Physical Condition(s) Sensitive information should not be detailed in the Alerts due to general access to this area but documented in the Progress notes. Use Other to record vulnerable in hot conditions / winter etc. Page 24
6.3.2 Adding an Alert & Maintaining Alerts Case Record On the top left hand corner of the case record Click on link Then Add Alert and The Alert link will turn red and display the date of the latest Alert To remove an Alert, click on the Alert Icon and click Remove Selected.. Tick the box next to the Alert you need to remove To view all the Alerts that have been removed, click Show History. 6.3.3 Risk Incidents The Risk Incidents screen is generally used for adding historical risks, as newly occurring risks will tend to be flagged via a Progress Note. Case Record >Risk Information > Risk Incidents Select the relevant Risk Types and use >> to move to the Selected area Record details of incident & If exact date is not known tick Date is approximate box 6.3.4 Risk Assessments A risk assessment should be completed for all Clients who may be at risk or displaying risk behaviours. It should be completed for all Clients who are inpatients and all Clients reviewed under the CPA process. Case Record >Risk Information > Risk Assessment Complete the form & Details of why a risk has been assessed as such or not, should be recorded, in detail, in the free text box under each section. Any additional assessments (e.g. specialist assessments, should be noted and summarised in the free text boxes) Page 25
6.3.5 Risk Management Plans Risks identified using the Risk Assessment should prompt a Management Plan to be completed. In RiO Risk Management Plans are called Care Plans. See Care Plans (5.3.1) 6.3.6 View / Print a Risk Summary Whenever a risk is identified it is highlighted on the Case Record Front Page in red, giving the date of the risk and how it was flagged on the system e.g. via a Progress Note. To view a summary of the risks which have been identified click on the LATEST RISK INFORMATION link. 6.3.7 Print a Point in Time Risk Summary Case Record >Client Related Data-Views > Risk Overview point in time Enter Date & 6.3.8 HCR-20 You must have specialised training to be able to complete the HCR-20 Assessment. Only those that have had this training should complete the information in RiO. Case Record >Risk Information > HCR-20 Page 26
Section 7 - Care Programme Approach (CPA) 7.1 General Principles Staff should refer also to the CPA Policy and Best Practice Guidelines. If it is a member of health staff who is the care coordinator for a client then CPA details should be completed on RiO following the below process. All sections need to be completed as outlined in the Process / Procedure. Paper copies of care plans should only be circulated to staff who do not have access to Ridgeway RiO. 7.2 The Process 1. Record CPA Episode Patient identified as needing to be supported by the CPA process Provisional date set for first meeting 2. Record all contacts Record all the personal contacts on RiO There is no need to include other HCPs who use RiO 3. Complete Core Assessments Assessments & Care Plans should be done as routine from the time a patient is referred to services, therefore this should not be seen as an additional task As appropriate start writing Care Plans, Risk Assessments 4. Book Meeting Schedule the review and invite attendees 5. Record outcome of review Complete the review details Update the Care Plans, Risk Assessment and Crisis Plan Record who the Care Plan is distributed to 6. Validate the Review Validate the Review If requried -print the CPA for external agencies / the patient 7. Book next meeting Record the provisional date of the next meeting OR Scheule the next review date Page 27
7.3 The Procedure 7.3.1 Record a CPA Episode Case Record > Care Planning, CPA and Reviews > CPA Management Complete details & CPA Episode Start Date / Time date it was decided this person should be supported under CPA Current CPA Level Always Enhanced Now set a provisional date for the meeting Click From the CPA Management Page next to Provisional Next Review Date/Time enter details & Now record all contacts 7.3.2 Record all Contacts Case Record > Full Name (ClientID) > Client Personal Contacts Edit this client > Add New Contact Completed the details & for the Address Repeat until all the Contacts have been added Now ensure all Core Assessments are completed The following Forms under Core Assessments must be completed when assessing a client under CPA: Presenting Situation & Referral Outcome Decision Mental Health History Physical Health History Personal & Family History Social History/ Care Management Form Substance & Alcohol Use Mental State Examination Physical Health Assessment Depending on the client, the other forms which make up the Core Assessment may also need to be completed. As well as the Core Assessment you must complete the following: Social Inclusion Form MCA & Information Sharing HoNOS-LD or HoNOS-secure Page 28
7.3.3 Complete Core Assessments Case Record > Core Assessment > Core Assessment Select the relevant assessment form from the list Click Add or Create New Complete the form & Repeat the process for the other forms Now complete Social Inclusion Form, Case Record > Social Inclusion Complete the form & Now complete HoNOS Case Record > Outcome Measures > HoNOS-LD NB in the Forensic Service it may be more appropriate to complete HoNOS-secure (v.2) Complete the form & Now complete Risk Assessment Case Record > Risk Information > Risk Assessment Complete the Risk Assessment form & Now complete Care Plans as appropriate Case Record > Care Planning, CPA and Reviews > Care Planning Select New Problem/Need, enter details & Click Care Planning to return to the options Select the Need you have just entered by clicking anywhere on it (it will highlight in pink) Select New Goal/Intervention, enter details & Now Schedule CPA Meeting NB Care Plans and Risk Management Plans are one and same thing on RiO please refer to the Sections on Care Plans and Risk Information for more details. Care Plans around managing risk MUST be completed on RiO but refer to the 5x5 matrix scores for situation prior to intervention AND residual risk Page 29
7.3.4 Book CPA Meeting Case Record > Care Planning, CPA and Reviews > CPA Review > Schedule CPA Review Complete review date details and add participants Add Additional Contacts as necessary HCP Ridgeway RiO User Client Contact Select from all people added to Personal Contacts Ad Hoc - type the name in When prompted Save Without an Appointment If warned of clash of appointment for some participants, click Yes, otherwise the review will not be scheduled Following CPA Meeting, complete Outcome of Meeting NB: It is better to ensure that all client contacts are recorded in the Client Personal Contacts page and only use Ad Hoc for people who may only be involved with the client for that particular review e.g. a member of staff from a new provider, etc 7.3.5 Record Outcome of Review Meeting Case Record > Care Planning, CPA and Reviews > CPA Review Outcome this Review Complete all the details & Review Type This will usually be Referral Review (use Discharge Review when client is leaving inpatient services) to pull through latest HoNOS score and employment / accommodation details Now update Care Plan Case Record > Care Planning, CPA and Reviews > Care Planning Click on the Need or Intervention which requires amending (it will highlight in pink) Click Edit Selected, amend details & Add New Problem/Need and New Goal/Intervention as required To close a Need or Intervention, click to highlight and select Close Selected Now Complete the Crisis Plan Case Record > Care Planning, CPA and Reviews > Crisis, Relapse & Contingency, enter details & Now Validate Review Page 30
7.3.6 Validate the CPA Review Case Record > Care Planning, CPA and Reviews > CPA Review Edit/Validate this Review To Validate the Review Check Validated box (in list at bottom of form) Now book the (provisional) date of the next meeting If required you can print the Care Plan. A care plan should only be printed for staff without access to RiO and for the Client / Carer. All staff with access to RiO should view the outcome of the CPA meeting in the Progress Notes, and under care Plan To Print: From Case Record > Care Planning, CPA and Reviews > Care Planning > Printable Care Plan. This will open a Word document which is fully editable. 7.4 Additional Information The Care Coordinator should be updated on RiO as required. 7.4.1 To change the CPA Care Coordinator Case Record > Care Planning, CPA and Reviews > CPA Management Date/Time of Change When the new Care Coordinator took over Date/Time of Change When the new Care Coordinator took over NB: The CPA Episode start date cannot be changed; if this is incorrect, the Episode will need to be reversed Page 31
Section 8 - Inpatient Management 8.1 General principles All referrals to Inpatient Services must have a referral created on RiO. All patients will be allocated to a bed or accounted for as a ward attender. It must be made clear if the client is on leave, AWOL or temporary transfer. The transfer of clients to other wards for sleepover will be the responsibility of the transferring ward. The ward they are sleeping on will be responsible for keeping progress notes of the client. When a client is transferred back this will be completed by the ward the client has slept on. Ward round / clinical team meetings outcomes should be entered on to the Client s progress notes. MHA status can only be updated by the MHA Administrator any change of status has to be communicated to the MHA Administrator. All discharges from inpatient services (Finished Consultant Episodes FCE) must have a diagnosis confirmed against them. Only Psychiatrists should assign / confirm a diagnosis for a Client. On the Ward bed view, if a bed has a green cover it is occupied; if it doesn t it is empty. Your bed layout view should directly correlate to the physical location of the patients. If patients are moving to another ward within the Trust, they should be transferred rather than discharged and re-admitted. 8.2 The Process Referral received Referral to 'New Referral' bucket made Admission planned Assessment screening commenced as appropriate Admitted to ward Recorded in bed Assessments / Care Planning commenced Progress notes written for all clinical encounters Even prior to admission assessments should be started Care Plans to be entered on RiO as required Risk Assessments to be completed as required All events recorded Leave, Transfers, Sleepovers and AWOL all recorded on RiO Ward information kept up to date Discharge from Unit Discharge planning & then discharge from unit Diagnosis Code to be entered and confirmed against admission Follow up within 7 days All patients must be followed up within 7 days of discharge and this recorded on RiO Page 32
8.3 The Procedure 8.3.1 Creating a New Referral Case Record > Client Referrals > Entry / Exit Create New Referral Complete details & Referral Date Time This is the date you received the referral Care Setting Always Community Team Team Referred To this should be the New Referral bucket for your area HCP Referred To this should always be left as None- Administrative Category usually NHS patient, including overseas visitors 8.3.2 Transferring a Referral to a Waiting List Once a referral has been accepted on to a waiting list for admission, they should be transferred to the Waiting List bucket on RiO Case Record > Client Referrals > Entry / Exit Transfer against the New Referral Select the Waiting List for your area & Enter details & 8.3.3 Discharging a Referral If a referral is inappropriate or a service cannot be provided then the New Referral should be discharged with a comment as to why a service could not be offered. If a Patient is admitted into Inpatient Services the referral to the Waiting List bucket must be discharged with a comment to say the Client has been admitted. Case Record > Client Referrals > Entry / Exit Click against relevant referral Enter details & 8.3.4 Admitting a patient into a bed Wards > select ward & Click on an empty bed Admit Search for the client Complete admission form & Client Classification Ordinary Admission Administrative Category NHS Patient, including overseas visitors Page 33
8.3.5 Recording a Ward Attender All Clients who attend the ward for whatever reason must be accounted for. If they are not going to occupy a bed then they need to be recorded as a Ward Attender Wards > select ward & Scroll to bottom of the ward Click Add Ward Attender Search for Client Enter date 8.3.6 To Discharge a Client Wards > select ward & Click on relevant Client bed > Discharge > Discharge Patient Complete details & Ensure that discharge address is entered 8.3.7 Planning an event You can plan an admission, discharge, leave, transfer or sleepover. Ward Planning Diary > select ward and date & click (week / Month) Click in the relevant box, date and bed Complete details Search for the client if admitting Complete details & Once event happens, see recording a planned event 8.3.8 Authorising a Planned Event A Planned event must be Authorised before it can be Recorded Ward Planning Tabular View All Mode > select ward Click on the Unauthorised Event (it will highlight in peach) & Page 34
8.3.9 Recording a Planned Event Ward Planning Tabular View Ward Mode > select ward Click on the planned event (it will highlight in peach) & Enter the exact date and time of admission & 8.3.10 Recording a Patient as a Delayed Discharge Discharge plans should be considered from the time of admission. If a patient finishes their treatment programme and is ready for discharge, but discharge is not possible, they should be recorded as a delayed discharge on RiO. Wards > select ward & Click on the relevant Clients bed > Case Record From the Case Record > Inpatient Management > Delayed Discharge Complete the details & then 8.3.11 Record a Patient as on Leave All Leave must be recorded on RiO for all Patients. Wards > select ward & Click on the relevant Clients bed > Leave > Leave Details Enter details & Leave Reason if patient is on Section should be recorded as Section 17 leave. If patient is informal / voluntary then Home Leave or Trial Leave should be used 8.3.12 Record a Patient as AWOL Wards > select ward & Click on the relevant Clients bed > Leave > AWOL Enter details & To return the patient from AWOL, repeat the above steps but select > Return from AWOL instead Page 35
8.3.13 To swap patients between beds Two patients can swap beds they can be on the same ward or different wards Wards > select ward & Click on the relevant Clients bed > Transfer Bed > Bed Swap Enter details of the two patients that are to swap beds & 8.3.14 To move a patient to a vacant bed A patient can be moved into a vacant bed, either on the same ward or a different ward. This screen is also used for changing the Consultant or Named Nurse for the Patient Wards > select ward & Click on the relevant Clients bed > Transfer Bed > Out Click in the section where the information needs to change Enter details and Transfer Date & 8.3.15 Recording a patient as Sleeping Over in another unit If a patient is sleeping overnight on another unit, then they must be recorded as on sleepover Wards > 8.3.16 Reversing an Inpatient Admission Entered in Error Click on Click on Reverse IMS Admission Search for the client Page 36
8.3.17 Adding a Diagnosis (ICD-10 code) Assigning a diagnosis to a Client should only be done by a Psychiatrist. All Clients discharged from inpatient services (Finished Consultant Episodes (FCE)) should have a diagnosis confirmed against their admission. Case Record > Diagnosis Click Enter a code or a word in the Search for: box and (don t enter any dots (.) e.g. F701 Click on the appropriate entry in the search results (will highlight in blue) Enter a Date of Diagnosis & 8.3.18 Confirming a Diagnosis Relating to Discharge from Inpatient Services (Finished Consultant Episode) Prior to confirming a diagnosis, all relevant diagnoses must firstly have been added Case Record > Diagnosis Click Event Type Finished Consultant Episode Click Event to Confirm use the dropdown to select the relevant Discharge Click Select the Primary Diagnosis from the drop down and use >> to move any secondary diagnoses to the Selected Diagnosis area 8.3.19 To Show Confirmed Diagnoses Click Case Record > Diagnosis Page 37
8.3.20 Recording Reading Patient s Rights All Sectioned patients should have their Rights read to them on a regular basis and this needs to be recorded in RiO. As a general guide patients on a Section 2 should have their Rights read weekly, those on a Section 3, 37 or 37/41 should have them read monthly this should be taken as a guide only as it may be appropriate to read Rights more often, depending on the Patient Case Record > Mental Health Act > Section 132 Rights Click Enter details & 8.3.2 To View a Client s Section History Only the Mental Health Administrator should enter details about a Client on RiO. However you can view a printable history of the Sections a Client has been on (with associated dates) Case Record > Mental Health Act > Client Section - History Page 38
Section 9 Referrals, Diary Management & Activity Data 9.1 General Principles All Client related activity must be recorded in your RiO diary. To record activity there must be an open referral to the relevant team. No activity should be booked against a referral to an Ongoing Care bucket (team). All appointments must be entered in the RiO diary in a timely fashion and by the 3 rd of each month at the latest. All appointments must be Outcomed in a timely fashion. To ensure waiting times can be calculated, the assessment appointment must be booked as First Appointment. Department of Health guidance advises that if a Client has not been seen for six months they should be discharged from the service. Decision to discharge a client is made by a clinician but this can be supported by administrative staff. It is the clinician s responsibility to ensure safe & appropriate discharge and their name should be entered into RiO as the discharging HCP. Discharging a client will not remove their details from RiO. Their case record will still exist but their name will be removed from the Team Caseload. A subsequent new referral to the Team can be made at any time. Referrals should be managed to ensure Clients are seen within the agreed waiting times. 9.2 The Process Add Referral Add referral to new referrals bucket Transfer referral to relevant profession Allocate referral to specific HCP Enter appointment in Diary Book appointment with Client and enter it in diary If assessment, book the appoint as 'First Appointment' or 'New Patient Assessment' Outcome appointment Following appointment - Outcome as soon as possible afterwards Close referral Once the treatment programme is complete, close the referral. If the Client has not been seen for six months, close the referral and then re-refer if necessary. Page 39
9.3 The Procedure 9.3.1 Creating a Referral Case Record > Client Referrals > Entry / Exit Create New Referral Complete details & Referral Date Time This is the date the referral arrived with the Team Care Setting Always Community Team Administrative Category usually NHS patient, including overseas visitors 9.3.2 Transferring a Referral If a referral has not yet been allocated to an HCP it can be transferred to another team. Generally referrals should be added to a New Referrals Team and transferred to the relevant Professional Team Case Record > Client Referrals > Entry / Exit Transfer against the relevant referral Select the relevant team & Enter details & 9.3.3 Discharge a Referral Case Record > Client Referrals > Entry / Exit Click Enter details & against relevant referral NB If you have finished working with a Client but somebody else in your team is still working with them, do not discharge the referral, but Reallocate to the other HCP (See 9.3.6) 9.3.4 Managing New Referrals Case Record > Client Referrals > Entry / Exit Click anywhere on the relevant referral Page 40
From the referral status screen, the urgency and waiting list status can be updated and amended and actions relating to the referral can be added. Updating Urgency and Waiting List Status Referral Status Change the details as required and click on the relevant line Adding an Action Referral Status Select details & 9.3.5 Allocate a Referral to an HCP Referrals should only be allocated to an HCP by the Team Leader. Allocations are done from the Team Leaders Caseload. Team referrals show up highlighted in dark pink or with a _T_ next to them Caseload next to the relevant Client > Allocate Enter details & 9.3.6 Reallocating a Client or Sharing a Client with another HCP Caseload Transfer Select the relevant Team & Allocate From - Choose the HCP that the Client is currently seen by Allocate To - Click on the HCP to Allocate To, enter the date then Tick the box next to the Client(s) that is to be Shared or Reallocated 9.3.7 Caseload Management All accepted referrals to the Team will be dealt with in a timely fashion. Appropriate referrals will sit on the Lead HCP s caseload until they are allocated to a specific HCP within the Team. During this time they will be the responsibility of the Lead HCP or a designated person within the Team to allocate clients to particular team members. A Team caseload or an individual caseload can be viewed to stay on top of activity referrals and those that need discharging / allocating / reallocating Caseload or Team Caseload The contents of a column on the caseload can be sorted if the arrow turns to a hand NB: The action button can be used to directly Book Community Appointments (which reduces time rather than searching for a Client if booking via the diary) Page 41
9.3.8 Removing a Client from a Caseload If a Client has been discharged or they have been shared with another HCP, you will be able to remove them from your Caseload View Caseload Tick the box by the relevant Client 9.3.9 Viewing a Printable Caseload View Caseload Select the relevant HCP & The list can be sorted by clicking in the top row over a particular column 9.3.10 Diary Management All Client related appointments must be booked into your RiO Diary. To book an appointment you must first have an open referral to your team Diary Navigate to the date you want using Or (to move one day at a time) & Click on the time you want to book the appointment Search for the client (if you haven t booked directly via on the caseload Enter details & NB Repeat appointments can be booked by ticking Book Repeat Appointments and filling in the details Remember to uncheck the Face-to-face Contact box if the appointment is not directly with the Client Carer Appointment cannot be ticked unless the carer is registered on RiO. If the appointment is with a carer uncheck the Face-to-face Contact box Appointment Type MUST BE First Appointment if the appointment is to be used for calculating waiting times. Otherwise select the most appropriate option. Page 42
9.3.11 Adding / removing another Client to an appointment Diary Navigate to the relevant date using (to move one day at a time) Or & Click on the time of the appointment Search for Client & To remove a client Tick the box next to the relevant client and 9.3.12 Adding / removing another HCP to an appointment Diary Navigate to the relevant date using Or (to move one day at a time) & Click on the time of the appointment Other HCP for HCP or select from dropdown of members of your team To remove an HCP Tick the box next to the relevant HCP and 9.3.13 Cancelling an Entire Appointment Diary Navigate to the relevant date using (to move one day at a time) Or & Click on the time of the appointment Enter details & Page 43
9.3.14 Outcoming an Appointment Diary Navigate to the relevant date using (to move one day at a time) Or & Click To Outcome next to the relevant appointment Enter details & 9.3.15 Booking / Cancelling non-client related Appointments RiO will be used primarily to book client contacts/appointments but other activities can be booked in the diary such as Training, Meetings, Absent, Travel, or Leave. Diary Navigate to the relevant date using (to move one day at a time) Or & Click in the centre of the diary (under Location/Other Activity) against the relevant time Enter details & To remove Click on relevant time in the diary & 9.3.16 Viewing a Printable Diary View Appointments Select HCP & The list can be sorted by clicking in the top row over a particular column 9.3.17 Viewing a Client s Diary Case Record > Client Related Data-Views > Client Diary View Enter the date range & Page 44