RiO Handbook & Quick Reference Guide

Transcription

1 RiO Handbook & Quick Reference Guide RiO Handbook Draft V1.2-13/05/2010 1

2 1. Introduction What Is RiO? 3 Benefits of RiO to Staff 3 Benefits of RiO to Service Users 3 Information Governance 4 2. Quick Reference Guides Logging On / Logging off 5 RiO Toolbar 6 Search 1 Local Searching 7 Search 2 National Searching 8 Search 3 Advance National Trace 9 Case Record 10 Referrals (Entry/Exit) 11 Caseload 12 Caseload Transfer 13 Creating a Local Record From The National Record 14 Updating National Record To Match Local RiO Record 15 Postcode Database Key Problem 16 Progress Notes 17 Printing Progress Notes 18 Care Planning Adding a new care plan 19 Client Diary & Client Death 20 HCP Diary - Booking Appointments 21 HCP Diary Outcoming Appointments & Cancelling appointments 22 Clinic Appointment Booking & Appointment Outcome 23 Clinic Plan, Clinic View & Cancel Appointment 24 Printing Clinic Lists 25 Document Upload 26 Edit & Print Letters Appendices Ward Management 28 Mental Health Reports 29 Safeguarding Children & Adults 37 Progress Note Guidance 40 Mental Health Forms 41 RiO Staff Code of Practice 52 RiO guide to using ICD Registering a Carer on RiO 61 RiO Handbook Draft V1.2-13/05/2010 2

3 1. Introduction What is RiO? RiO is part of the National Programme for IT. It is an electronic service user record system, designed to replace the existing systems in u se, PAS. epex, PARIS and Care First 6. Benefits of RiO to Staff: Provides staff with access to live, up-to-date electronic records, notes, care plans, bed plans and risk assessments, through the use of a 'Smartcard' and unique PIN Reduction in the amount of paperwork staff need to complete, as all referrals, clinical notes, care plans and more, will be completed electronically More than one user will be able to access one service user s record at any time, from any networked location in the Trust Increased security with all information and notes kept electronically in one safe place, coupled with the level of access granted to staff based on what information they need to do their job fully Allows staff to communicate more effectively within teams, and across the Trust, particularly regarding service user care plans and referrals The elimination of problems such as illegible handwriting and duplication Benefits of RiO to Service Users: RiO will keep all service user records and notes in one safe and secure place, improving security as files will no longer need to be moved between sites By enabling staff to communicate quickly and more effectively across the Trust, RiO should provide a more complete and consistent level of care. Staff will be able to quickly access care information when it's needed, resulting in safer diagnosis and treatment for service users Please note: All service users will be referred to in the handbook as clients/patients due to this terminology being used within RiO. RiO Handbook Draft V1.2-13/05/2010 3

4 Information Governance Information Governance ensures all service user records are kept confidential and personal. Everyone in the Trust has a responsibility for protecting service user, carer, staff and volunteer s information regardless of job role or position. This involves ensuring that all information is stored safely, stays private and is accessed appropriately. To achieve this, all employees must act in compliance with Clinical Governance, the Caldicott principles and the Data Protection Act The Caldicott principles and the Data Protection Act 1998 are summarised below: Keep personal information secure: do not share your passwords or pin-code with anyone. Remember to Log-out when you have finished using the computer. Keep personal information confidential: Justify your reasons for accessing the information and only disclose to those who need to know. Do not discuss personal information about your service users in corridors or lifts! Keep personal files in a locked area. Ensure the information you use is obtained fairly: let the service user know the reason their information is being stored and who will be able to access their information in compliance with the Data Protection Act (1998). Make sure the information you are using is accurate, relevant and up-to-date by checking personal information with the service user. Use the information in an ethical way, i.e. for the purpose it was given. Obtain service user consent before sharing their information with other agencies. Comply with the law and remember the Trust policies and procedures for safeguarding information. For more information visit the Trust s Intranet. RiO Handbook Draft V1.2-13/05/2010 4

5 2. Quick Reference Guide Logging On Insert Smartcard to display Passcode dialogue box. Select job role (this is only required if you have more than one contract with DHFT or are employed with more than one Trust). Logging Off ALWAYS ensure you click on Smartcard. before removing your RiO Handbook Draft V1.2-13/05/2010 5

6 RiO Toolbar A Back button, which is only visible after you have moved away from your home page it is not there when you first log on because there is nowhere to go. A Help button. Click this to see help for your current location. About An About hyperlink. Click this to see copyright and other details about the system. A Printer button. Caseload Your current location. A Reset Timeout button this is described in lesson about logging on to RiO. Anne Jones Your name. CHTRAIN The system you are using either the training or the live environment. Log Off A hyperlink to log you off the system. RiO Handbook Draft V1.2-13/05/2010 6

7 Search 1 - Local Searching 1) Click on the Client Record icon and select Case Record. 2) Demographics (Search) screen is displayed. 3) If you have it, search using the NHS number and click on the Go icon. 4) If you do not have the NHS number enter as much information as you have available i.e. family name (surname), given name (first name), gender, date of birth and postcode. 5) If client found click on their name to view their demographic details. OR If no client found attempt further local searches before attempting National Search. RiO Handbook Draft V1.2-13/05/2010 7

8 Search 2. National Searching 1) To conduct a National Search the box below will require Family Name, Date of Birth and Gender as the minimum search requirement. 2) If a simple trace of the national record does not return a match, the user has the option to perform an advanced trace search. If client found click on their name to view their demographic details. RiO Handbook Draft V1.2-13/05/2010 8

9 Search 3. Advanced National Trace Searching 1) When a simple trace of the national records returns no match, the following message is displayed. 2) Click Yes to perform an advanced trace. An advanced trace can return multiple possible matches and will search historical information. 3) If the client record is not located nationally, contact Applications Service Desk on to register a new client. Be ready to provide as much detail about the client s demographics as you can. RiO Handbook Draft V1.2-13/05/2010 9

10 Case Record 1) Click on the Client Record icon and select Case Record. 2) Search for the client and select a reason for accessing the client s case record. Record any comments as appropriate and click on Save. 3) Case Record screen is displayed. The top left area of the screen allows you to access/record Alerts and view consent (RiO Consent is now recorded by GP s only. Please note that Carers information and non healthcare information does not require consent to be recorded on RiO. The bottom left area of the screen displays key client demographic information. The right area of the screen displays folders that allow you to access various client related forms/functions. RiO Handbook Draft V1.2-13/05/

11 Referrals (Entry/Exit) 1) From the Client s Case Record select Client Referrals and Entry/Exit from the right hand side. 2) The client s Referrals screen is displayed. 3) Click on Create New Referral at the bottom of the screen to enter a new referral. 4) Complete all mandatory (green) fields. 5) Referral Received date needs to be completed with the date the referral arrived at the service. Referral Accepted date should be left blank. N.B Referrals are predominately sent to teams rather than individuals, therefore the HCP Referred To field should be set to NONE. Other referral options: 1. Click on Transfer to transfer the referral to another team in the service. 2. Click on the discharge button to discharge the referral RiO Handbook Draft V1.2-13/05/

12 Caseload 1) Click on the Client Record icon and select Caseload. 2) Caseload screen is displayed for the default Health Care Professional (HCP). 3) The details of the clients on the HCP s caseload are displayed in the main area of the screen. 4) To view another HCP s caseload, select a different HCP from the drop-down list at the top of the screen and click on GO. 5) To allocate a client who has been referred to the team to a HCP, click the radio button in the Alloc. column and select Allocate. Choose the HCP you wish to allocate the client to and save. RiO Handbook Draft V1.2-13/05/

13 Caseload Transfer 1) Click on the Client Record icon and select Caseload Transfer. 2) Select the correct team and click on GO. 3) Select the HCP from whom you wish to transfer clients and click on GO. 4) Caseload Transfer/Allocation screen is displayed. 5) Select the HCP to transfer to from the Allocate To list. 6) Enter a transfer Start Date. 7) To share clients with another HCP, put a tick in the checkbox next to the correct client(s) in the Share column. OR To reallocate clients to another HCP, put a tick in the checkbox next to the correct client(s) in the Reallocate column. 8) Click Allocate Caseload Item(s). RiO Handbook Draft V1.2-13/05/

14 Creating a local record from the national record Used for individuals new to RiO but already registered on the National Database. 1) Select Registration from Client Record icon and search for client. If no record found locally carry out a national search. If client exists Nationally then select them. 2) The Client Details page is displayed, showing sections for Local Data and NCRS National Data. 3) Yellow highlighting will indicate the fields which contain data. There will be no data held locally at this point. 4) Click the checkboxes on the right side of the dividing line to select the national information to transfer to the local record. 5) The Person s Role will be selected as client by default, change as required. 6) Select an Ethnicity from the drop-down list in the local data section. 7) Click Save to Local Only. 8) The Client Details page is displayed, showing both local and national copies of the information. RiO Handbook Draft V1.2-13/05/

15 Updating national record to match local RiO record Used when the client is already registered locally and nationally and some details require updating. 1) Using Registration search for the client and select. 2) The Client Details page is displayed, showing sections for Local Data and NCRS National Data. Click Edit this Client. 3) Change demographic details as required using the Local Data side. N.B. You can no longer change the GP details, this must be done by the GP. 4) When finished click Save to Local and National. 5) A message is displayed warning that you are about to update the central record. Click Yes to continue. 6) The new information is displayed on both sides of the dividing line. RiO Handbook Draft V1.2-13/05/

16 Postcode Database Key Problem 1) Initially all locally held address records on RiO will be missing the postcode database Key. The database key is required by V5 RiO as it identifies the client s home as opposed to just part of the street. Such information should hopefully resolve some address mistakes. 2) Enter the Local and National Database synchronisation screen (see Synchronisation section). If address is highlighted as a problem area, select the Address tick box on the Local Database side. The following message is displayed. 3) Press OK. 4) If the address displayed is complete and correct simply press Search. 5) The address is now displayed. Press Accept Address to confirm. 6) Click Save to Local & National to update both the locally held RiO record and the National Record. 7) You will now be advised that Saving changes will update the Spine continue with save? this is correct 8) If you get an error message, click Yes. You might get a second error message; also click Yes RiO Handbook Draft V1.2-13/05/

17 Progress Notes 1) Select Progress Notes from Case Record Screen. 2) Click on Add New Note to create a new progress note. 3) Enter the text of the progress note. 4) If applicable identify the following areas. 3. This Note Contains Third Party Information (tick box). 4. This is a Significant Event (tick box). 5. Add to Risk History (tick box & select Risk Type(s)). 5) If you wish to validate the note, tick the Validate this Note box. 6) Click on Save Changes. RiO Handbook Draft V1.2-13/05/

18 Printing Progress Notes 1) In the Case Record select Client Related Data-Views and then Progress Note View. 2) Select required service using Progress Note Type. 3) Specify Start Date and End Date. 4) Press OK. 5) Requested Progress Notes are now displayed on the screen and can be printed using the Print button available at the bottom of the screen. RiO Handbook Draft V1.2-13/05/

19 Care Planning - Adding a new care plan 1) From the Case Record screen, click on the Care Planning folder, select Care Plan. 2) Care Planning Client screen is displayed. 3) Click on New Problem/Need. 4) Select the Problem/Need type and enter a description of the problem you wish to add. 5) Click on Save and then Care Planning to return to the main care planning screen. 6) Click on the displayed problem to select, then click on New Goal/Intervention. 7) Enter relevant information about the intervention. 8) Click on Save and then Care Planning to return to the main care planning screen. RiO Handbook Draft V1.2-13/05/

20 Client Diary 1) Within the clients Case Record select Client Related Data- Views and choose Client Diary View. 2) Select the type of appointment and correct date range using the calendar icons then click on GO to view appointments. Note: Click on the REF - 1 hyperlink (located at the end of each appointment) to identify Team/Speciality and other referral details. Client Death 1) Registering a client is now done centrally. To Record client death please ring Applications Service Desk on Important Note: Upon disclosure of death staff should immediately make sure all Progress Notes, Diary & Clinic Outcomes etc are complete. RiO Handbook Draft V1.2-13/05/

21 HCP Diary Booking Appointments 1) Click on the Appointments icon and select Diary. 2) Check & select the correct HCP and Date and click on GO. 3) Click a Time alongside a vacant slot in your diary and Search for the client. 4) Ensure the following details are correct: a. Appointment Type. b. Location. c. Intended Duration. d. If this is an appointment with a carer, select Carer Appointment. e. If this is not a face-to-face contact, clear this box. 5) Click on Book Appointment to create the appointment in the HCP s diary, then click on HCP Diary View to return to the diary. RiO Handbook Draft V1.2-13/05/

22 HCP Diary Outcoming Appointments 1) From the HCP Diary, click on To outcome (this will only appear on the current day, or days in the past) 2) On the following screen, click on the golden O 3) You now get the following additional fields: 4) Complete the Seen time and the Outcome (from the drop down list) and any comments that you wish to make. 5) The following screen is then displayed: 6) Click on View if you wish to see the previously entered outcome. HCP Diary Cancelling Appointments 1) From the HCP diary, Click on the time next to the appointment 2) Click on Cancel 3) Enter the cancellation reason 4) Click on Cancel this appointment. RiO Handbook Draft V1.2-13/05/

23 Clinic Appointment Booking 1) From the Clinic View screen, click on the start time of the slot you wish to book. 2) Search for the client. 3) Ensure the following details are correct: 6. Appointment type 7. HCP 8. Intended Duration 4) Click on Book Appointment to create the appointment. Clinic Appointment Outcome 1) From the Clinic View screen, click on the small black arrow in the Outcome column. 2) Click on the golden O button. 3) Enter an Arrival Time, Actual Duration and Seen Time, then select an Outcome and click on Save. 4) To view an outcome in more detail from the Clinic View, click on the outcome text. Please Note: Outcomes must be completed within 48 hours. RiO Handbook Draft V1.2-13/05/

24 Clinic Plan 1) Click on the Appointments icon and select Clinic Plan. 2) Clinic Plan screen is displayed. 3) Select the correct clinic and click GO. 4) Enter the Start Date of the first session you wish to view, select the number of Clinics you wish to view then click on GO. Click on a free slot in a clinic to book an appointment into that slot. Click on the date of a clinic session to view the clinic for that day in detail. Clinic View 1) Click on the Appointments icon and select Clinic Appointments. 2) Clinic screen is displayed. 3) Select the correct Clinic ID and click GO. 4) Select the correct Date and click GO. A clinic view will be displayed for the clinic on the selected date. Cancel Appointment 1) From the Clinic View screen, click on the Appointment Start Time (for the client appointment you wish to cancel). 2) Clinic Appointment Details screen is displayed. 3) Click on Cancel. 4) Enter a Cancellation Reason and click on Cancel This Appointment. Please Note: Clinic appointment booking & outcome procedures may differ locally. Please check your operational policies. RiO Handbook Draft V1.2-13/05/

25 Printing Clinic Lists 1) In RiO select Appointments icon and choose Clinic Appointments. 2) Select appropriate Clinic ID and press Go. 3) Choose Date of clinic you require printing and press Go. 4) The requested clinic day is displayed including the Print Clinic List Button displayed below. 5) The clinic list information is transferred to a more printer friendly screen with the option to select printer. 6) Select Print. RiO Handbook Draft V1.2-13/05/

26 Document Upload 1) In the Case Record click Clinical Documentation. 2) Select Document Upload to upload a document (Select Document List View to view previously uploaded documents.) 3) Document Upload screen is displayed. 4) Click on Browse to search for the file. 5) Complete fields: Author Document Title - name of document e.g. GP Letter and a date e.g in less than 22 characters total. Document Type 6) Click on Upload Document. RiO Handbook Draft V1.2-13/05/

27 Edit & Print Letters 1) In the Case Record click Clinical Documentation. 2) Select Editable Letters. 3) Select the correct Letter Type from the list and click on GO to generate the letter in Word. 4) The letter selected will be displayed in Word (available from the taskbar), with the relevant client details included. 5) You can now make any necessary amendments to the letter and print or save it as you would a normal Word document. 6) To send the letter back into RiO, click on the Send to RiO icon in Word. 7) Complete the standard document upload fields. 8) Press OK. RiO Handbook Draft V1.2-13/05/

28 3. Appendix 1 Ward Management Vacant Bed Occupied Bed Occupied Leave Planned Bed Blocked On Leave Bed Vacant Blocked Leave Planned On Sleepover Vacant Bed Closed. AWOL Bed (Mental Health) Error Bed (Two patients admitted at same time) If two clients/patients are admitted to a bed (one on leave or on sleepover), details for both of them are displayed to the right of the bed: RiO Handbook Draft V1.2-13/05/

29 Appendix 2 Mental Health Reports 7 days 48 hours follow - up monitoring Description Criteria Display Monitor follow-up after discharge, identifying any unfulfilled requirements. Report primarily intended for use by Clinical Team Manager. This report opens in a new window. Start Date refers to the planned date of discharge recorded on the Pre-Discharge Planning form so only clients/patients with a planned discharge date on or after the Start Date are included in the report. End Date is the actual date of discharge. Only clients/patients with an actual date of discharge on or before the End Date are included in the report. To be included in the report, clients/patients must have: Is follow up needed? set to Yes and a value specified for Within 7 days or 48 hours? in the Pre-Discharge Planning form. At least one appointment on or after the date of discharge. The report only displays information for wards and caseloads appropriate for the person running the report. The client s/patient s name and ID, the actual discharge date, planned discharge date, an indication of whether a follow-up appointment is needed (yes or no) and the elapsed time (7 days or 48 hours) are displayed for all clients/patients. The date, type, team and HCP associated with each appointment are shown. If an outcome has already been recorded for an appointment, details of that are displayed too. Bed Availability by Hospital Site Description Criteria The current bed availability across a hospital site, sorted by ward and by bay within ward. This report opens in a new window. Hospital Site: either select a specific hospital site or leave the default of All to include all sites. Bed Type: either select a bed type or leave the default of All to include all bed types. RiO Handbook Draft V1.2-13/05/

30 Display A separate row is created for each bay in each ward, showing: The broad patient group and clinical intensity of the ward. The name of the hospital. The name of the ward this is a hyperlink that opens the Bed Layout View of the ward. The bay number. For each bay (row), the numbers of the following are shown: Total available (not closed) beds. Clients/patients on leave. Bed availability. Intended discharges. Expected admissions. Bed Availability by Ward Description Criteria Displays The current bed availability for a ward, sorted by bay within that ward. This report opens in a new window. Select Ward: either select a specific ward or leave the default of All to include all wards. Bed Type: either select a bed type or leave the default of All to include all bed types. The information displayed is exactly as described in Bed Availability by Hospital Site, filtered to show one row for each bay in the selected ward(s). CPA Levels Approaching Review Date Description Criteria Display Clients/patients whose CPA reviews are due in a specified number of days. This includes reviews scheduled for dates before the current date that have not had an outcome recorded. This report opens in a new window. Number of days to next review: everyone who has a review scheduled up to this number of days from the current date is included in the report. CPA Level: either specify a level or leave the default of All to include everyone who has a review scheduled within the time frame. The report shows the clients /patients name and RiO IDs, the CPA levels they are currently on, the names of the care co-ordinator and allocated HCP, the name of the allocated team and the scheduled review date. If the review date has passed and no outcome has been recorded for a review, the review is marked as Overdue. You can order the report by clicking on any of the column headings. Clicking on the same heading a second time reverses the sort order. RiO Handbook Draft V1.2-13/05/

31 Current Delayed Discharges Description Criteria Display A report showing clients/patients whose discharges have been delayed. This report opens a new window. Select Ward: either select a specific ward or leave the default of All to include all wards. HCP: either select a specific HCP or leave the default of All to include all HCPs. Basic demographic information about the client/patient is displayed (name, RiO ID, NHS number, date of birth, sex, ethnicity), taken from the demographic record. Information about the admission (date and time of admission, consultant and ward) are taken from the current inpatient event. The date discharge was planned, the reason for the delay, who is responsible for the delay and the number of days discharge is delayed by are taken from information entered on the Delayed Discharges form. In-Patient Activity by Site Description Criteria Display A report showing the number of client/patient movements for all wards within a selected hospital site or across all sites. This report opens a new window. All movements taking place on or after the Start Date and on or before the End Date are counted for the report. Hospital Site: either select a hospital site or leave the default of All to include all sites. A row is created for each ward showing the number of admissions, discharges, transfers in and transfers out. In-Patient Activity by Ward Description Criteria Display A report showing the number of client/patient movements for a single ward or across all wards. This report opens a new window. All movements taking place on or after the Start Date and on or before the End Date are counted for the report. Select Ward: either select a ward or leave the default of All to include all wards. A row is created for each ward showing the number of admissions, discharges, transfers in and transfers out. RiO Handbook Draft V1.2-13/05/

32 List of Active Clients Description Criteria Display A list of referrals relevant to the current user, which could be used for regular review meetings by team leaders and care co-ordinators. The list of teams in Select HCP team to filter by is restricted to the teams to which the user has access. ALL is every team in the list, not every team in RiO. The results are restricted to caseloads and wards that the user has access to view. Basic details (client/patient name, RiO ID, GP and practice) from the client s/patient s demographic record. Date of the referral letter, urgency, referral reason, source and referrer and the team from the referral record. The HCP who has been allocated this client/patient. The client s/patient s CPA level from his or her CPA record. The date of referral screening (date of assessment) and the referral screening outcome recorded in the Referral Screening form associated with this referral. Time Since Last Seen Description Criteria Display A list of clients/patients who have not been seen and do not have a face-to-face appointment within a specified number of days since the last appointment. This report is intended to help care co-ordinators and other clinicians to ensure that clients/patients are seen at an appropriate frequency. This report opens in a new window. Number of days since last appointment: only clients/patients who have passed this number of days (1 15) since their last appointment are included on the report. The report will only display clients/patients from caseloads or wards to which you have access. Clients/patients are not included on this report if their most recent appointment is within the number of days specified unless the appointment was cancelled or the outcome was recorded as DNA. Telephone contacts are not classed as valid appointments for the purposes of this report. Client s/patient s name a link to the Case Record. The date the referral was received. The name of the care co-ordinator and the CPA level of the client/patient. The team and HCP allocated to this client/patient. The date of the most recent appointment for this referral, the number of days that have elapsed since, the appointment type, the appointment outcome (if any) and the date and time of the next appointment (if any). RiO Handbook Draft V1.2-13/05/

33 List of Clients without a CPA Review Description Criteria Display A list of clients/patients who do not have a CPA review within a specified number of days since the last review. This report is intended to help care co-ordinators and other clinicians to ensure that CPA reviews are carried out at an appropriate frequency. This report opens in a new window. Number of days since last review: only clients/patients who have passed this number of days since their last review are included on the report. CPA Level: only clients/patients with this CPA level are included on the report. Leave the default of All to include all CPA levels. The report will only display clients/patients from caseloads or wards to which you have access. Client s/patient s name a link to the Case Record. The date of the last CPA review, the name of the care co-ordinator and the CPA level of the client/patient. The date that the most recent intervention was added to the client s/patient s care plan this forms a link to the care plan. Dates of the most recent risk assessments standard risk assessment or the HCR-20 forming links to the relevant forms. The date the crisis plan was last amended. The team for this client/patient. The date the next review is scheduled, if any. Missing Data Description Criteria Display This report displays clients/patients who are missing important data from their records. It can be used by service/team managers and system administrators. The report only displays clients/patients from caseloads or wards to which you have access. The two parameters are used to filter the results by surname. Specifying the same letter in both fields restricts the results to clients/patients whose surnames begin with that letter. Lists all clients/patient who have missing or incomplete data in the following fields: given name, NHS number, date of birth (including an estimated date of birth), marital status, sex (including unknown ), ethnicity (including not stated not requested ), CPA level, GP (including unknown GP codes of G ), post code (including ZZ99), care co-ordinator and past appointments without a recorded outcome. To help in obtaining the missing information, the client s/patient s daytime telephone number is displayed, as well as the date that registration details were last updated and the name of the person who updated them. RiO Handbook Draft V1.2-13/05/

34 Staff directory Description Criteria Display A list of members of staff by service and team. You can choose to view all staff for a particular service (or All to see staff for all services) and for a particular team (or All to see staff for all teams). For each member of staff, the report displays the person s full name, profession, whether or not this person is a care co-ordinator, the staff professional group to which this person belongs and the service(s) and team(s) associated with this person. Also shown are the person s work-based contact details (phone number, mobile number and address). Unencoded FCE's Description Criteria Display This report lists all finished consultant episodes that are not associated with a confirmed diagnosis. Select the consultant whose caseload you want to view. The list of consultants available to you is restricted to those whose caseload you have access to and your own clients/patients, if you are a consultant. Selecting All is equivalent to selecting every consultant whose caseload you have access to: it does not select every consultant specified in RiO. This report displays the client s/patient s full name, RiO ID, NHS number, date of birth, sex and ethnicity from his or her demographic record. Details of the last confirmed FCE for the client/patient are displayed, including the way in which it finished (discharge or transfer), the consultant responsible at the time, list of confirmed diagnosis codes, date when the diagnoses were confirmed and the person who confirmed them. A separate row is then displayed for each unconfirmed FCE for the client/patient, showing the name of the consultant responsible (which forms a link to the diagnosis page) and a list of eligible diagnoses (entered but not confirmed). User Roles and Descriptions Description Criteria Display This report is used by system administrators. It lists user roles and their corresponding descriptions. There are no user-set criteria. User roles and corresponding descriptions. RiO Handbook Draft V1.2-13/05/

35 Waiting List - Allocation to Assessment Description Criteria Display This report lists clients/patients on an HCP s caseload who are awaiting assessment. Clinicians can use this report to establish assessment priorities. This report opens in a new window. At Date: all clients/patients with open referrals at this date who have not been assessed are included on the report if they meet the other criteria. Urgency: specify the urgency of the referral using the drop-down list. This enables clients/patients with more urgent referrals to be prioritised. Leaving this at the default of All ignores urgency when selecting clients/patients for the report. Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral without an assessment are displayed on the report. You will only see clients/patients on caseloads or wards that you are authorised to view. The report displays basic demographic information for the client/patient, sufficient information about the referral to be able to identify it and the client s/patient s CPA Level and Care Co-ordinator from his or her CPA record. The time between allocation to an HCP and completion of assessment is calculated and displayed. The report is sorted by urgency and then by decreasing waiting time. Waiting List - Referral to Allocation Description Criteria Display This report lists clients/patients who have been referred but are not yet allocated to an HCP. This report opens in a new window. At Date: all clients/patients with open referrals at this date who have not been allocated to an HCP may be included on this report if they meet the other criteria. Urgency: specify the urgency of the referral using the drop-down list. Leaving this at the default of All ignores urgency when selecting clients/patients for the report. Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral without an assessment are displayed on the report. You will only see clients/patients on caseloads or wards that you are authorised to view. The report displays basic demographic information for the client/patient, sufficient information about the referral to be able to identify it and the client s/patient s CPA Level and Care Co-ordinator from his or her CPA record. The report is sorted by urgency and then by decreasing waiting time. RiO Handbook Draft V1.2-13/05/

36 Waiting Times - Allocation to Assessment Description Criteria Display This report lists clients/patients on an HCP s caseload who have been assessed. This report can be used to monitor waiting times against local or national targets. This report opens in a new window. At Date: all clients/patients with open referrals at this date who have been assessed are included on the report if they meet the other criteria. Urgency: specify the urgency of the referral using the drop-down list. This enables clients/patients with more urgent referrals to be prioritised. Leaving this at the default of All ignores urgency when selecting clients/patients for the report. Target Assessment Outcome Time (days): only clients/patients who waited longer than this period of time from referral without an assessment are displayed on the report. You will only see clients/patients on caseloads or wards that you are authorised to view. The report displays basic demographic information for the client/patient, sufficient information about the referral to be able to identify it and the client s/patient s CPA Level and Care Co-ordinator from his or her CPA record. The time between allocation to an HCP and completion of assessment is calculated and displayed. The report is sorted by urgency and then by decreasing waiting time. Waiting Times - Referral to Allocation Description Criteria Display This report lists clients/patients who have an open referral on the date specified and have been allocated to an HCP. The time from referral to allocation is calculated and displayed on the report. This report opens in a new window. At Date: all clients/patients with open referrals at this date who have been allocated to an HCP may be included on this report if they meet the other criteria. Urgency: specify the urgency of the referral using the drop-down list. Leaving this at the default of All ignores urgency when selecting clients/patients for the report. Target Assessment Outcome Time (days): only clients/patients who have waited longer than this period of time from referral before being assessed are displayed on the report. You will only see clients/patients on caseloads or wards that you are authorised to view. The report displays basic demographic information for the client/patient, sufficient information about the referral to be able to identify it and the client s/patient s CPA Level and Care Co-ordinator from his or her CPA record. The report is sorted by urgency and then by decreasing waiting time. RiO Handbook Draft V1.2-13/05/

37 Appendix 3 Safeguarding Children and Adults Safeguarding Children in relation to RiO (10/05/2010) This document is intended as a guide to how safeguarding issues are recorded in RiO reporting and other actions should be taken in line with the Trust policy and direct communication with colleagues is still required. As part of the initial assessment process, it is important to record family details particularly children for whom the client has caring responsibilities (parental or otherwise). However, the case record should be added to whenever information regarding relationships with children comes up and risk assessment should be an ongoing process at every contact. 1. Case Record Front Page Where to record relevant information: Client Demographics (Right side of front page): Select family management, click add members this will allow you to search RiO/Spine and pull through demographic details of family members. Dependants clicking on this hyperlink on the left side of the case record front sheet will allow you to add dependants to the record. Click Edit this Client and Add New Contact. You must select dependant from the first drop down menu in order for the name and relationship to appear on the front page of the case record. More than one dependant can be added in this way. 2. Referral screening use the risk box to identify any risk issues relating to children if known. 3. Core Assessment Part 2 Ongoing. There are a number of forms where information should be recorded depending on the situation. Under Personal and Social Information a) Personal and social information form use relationship section to record relationships with children either their own or those of friends and family. A Genogram should be uploaded at this point. 1 b) Care Management Form this allows you to identify that the person needs additional support to parent children and to record the support network e.g. child care arrangements. Where the need for additional support to parent children is identified, the action to be taken must be identified through care planning and referral to / liaison with the relevant agencies depending on need and in line with existing policies. Under Mental Health Act & Children s Legislation a) MH Act & Children s Legislation Form use this to identify if the client themselves is under 18 and on the Child Protection Register (CPR) b) Identify if they are a parent or carer for a child on CPR (the caring role may be informal and infrequent but still requires recording) and complete the details section. c) Any other dependant issues can also be recorded on this form e.g. vulnerable adults, pets etc. Forensic History For use when there is a known history of offending. 4. Risk Assessment a) Identify if the client is a risk to children and provide details regarding the nature of this risk b) Identify if they are on the Sex Offenders register/ Schedule 1 etc c) The level of risk should be identified in the summary box along with any buffers. The management plan should form part of the care plan. 1 This is an area for development within the Trust and training should draw on the existing expertise within the services. It should be considered good practice to develop a genogram for each individual seen by DPT. RiO Handbook Draft V1.2-13/05/

38 Safeguarding Summary Form is intended for use when the client is under 18 and should not be used otherwise. 5. Care Planning Where a risk to children is identified it should be included in the care plan and could be linked to areas of need such as: child care, family relationships, risk to others, sexual offences etc. The intervention type selected should be Adult Generic Safety & Risk Management. 6. Crisis and contingency planning should include the action to be taken with regard to dependents in the event of a crisis. 7. Progress Notes All concerns and actions in relation to safeguarding children in relation to a particular client must be documented immediately in the progress notes and the existing policy for reporting concerns should be followed. Progress notes should be linked to problems types as described above. The 3 rd party information box should be ticked as appropriate. The progress note should be linked to risk if the client poses a risk or is at risk themselves. If you are recording reporting a child in the client s family as at risk but not from the client, this might need to be linked as a significant event if it is likely to impact on the client s well being or relationship with services. NB if any progress note is linked to risk, the risk assessment also needs to be updated. Safeguarding Adults (10/05/2010) As with safeguarding children, this document is intended only to inform staff of when and where to record this information in RiO. All other processes including liaison with colleagues and external agencies should follow Trust policy and good practice guidance. 1. Case Record Front page There is a hyperlink in bold red to the latest risk information in the case record. This may be a risk assessment or a progress note that has been linked to risk. Keeping the risk assessment up to date and linking relevant progress notes to risk ensures that all clinicians within DPT who are working with the individual can access up to date information to support their practice. 2. Referral Screening/ Triage Use the risk box to record any relevant information that is known at this stage. 3. Core Assessment Part 2 Ongoing Information regarding safeguarding, particularly from the person s history may be recorded in a number of the forms here. Under Personal and Social Information a) Personal and social information form use family history section to record relationships within the family including those which present safeguarding issues. A Genogram should be uploaded at this point. 2 b) Relationships and Sexuality use this form to record current relationships and history of those and other prior relationships. Under Care Management a) Accommodation/Housing record others living with the person and any issues regarding these arrangements e.g. if they are unable to get a guest to leave, or the accommodation is being misused. 2 This is an area for development within the Trust and training should draw on the existing expertise within the services. It should be considered good practice to develop a genogram for each individual seen by DPT. RiO Handbook Draft V1.2-13/05/

39 b) Finance Record if there are issues regarding financial abuse including by those with legal powers over the person s finances. Under Mental Health/Children s Legislation a) If an adult protection register is in use and the person is on it, then that can be recorded here. This will then appear on the front of the case record. b) If the person has dependents this should also be recorded here. This information also needs to be recorded via the front page of the case record using the hyperlink Dependants on the left side of the case record front sheet which will allow you to add dependants to the record. Click Edit this Client and Add New Contact. You must select dependant from the first drop down menu in order for the name and relationship to appear on the front page of the case record. More than one dependant can be added in this way. c) In the case of domestic abuse situations where children are involved the risk to them should also be recorded on this form and elsewhere as indicated in Appendix 2. Under Mental and Physical Health Examination Where a physical injury is reported and observed, a body map annotation should be created to indicate the location and nature of the injury. Details of the incident reported should be recorded in Risk Information, Risk Incidents and/ or in a progress note which is linked to Risk History. 4. Risk Assessment This should be used to record risk of harm from others including domestic violence. The level of risk and the buffers should be identified in the summary box. The risk management plan forms part of the care plan. 5. Care Planning Care plans in relation to safeguarding issues should be linked to the appropriate need e.g. risk from others and the intervention type should be Adult Generic - Safety & Risk Management. 6. Crisis and Contingency Planning Should include the actions to be taken in terms of involvement/ non-involvement of others in the event of a crisis. Where the person is potentially at risk from their nearest relative and wishes to displace them, this should be recorded under Mental Health Act, Nearest Relative. 7. Progress Notes All concerns and actions in relation to safeguarding in relation to a particular client must be documented immediately in the progress notes and the existing policy for reporting concerns should be followed. Progress notes should be linked to problems types as described above. The 3 rd party information box should be ticked as appropriate. The progress note should be linked to risk if the client poses a risk or is at risk themselves. NB if any progress note is linked to risk, the risk assessment also needs to be updated. RiO Handbook Draft V1.2-13/05/

40 Appendix 4 Progress Note Guidance 1. INTRODUCTION PROGRESS NOTES GUIDANCE (10/5/2010) 1.1. Health and Social Care records should be contemporaneous, accurate and provide a comprehensive record of the implementation and effectiveness of interventions that utilise strengths and address assessed needs as set out within the person s care plan. In addition, the notes should be written in accordance with Professional Guidance. As a minimum Devon Partnership Trust expects staff to ensure that their notes comply with the following standards: If a person is supported on an inpatient unit, progress notes should be entered in the person s record in accordance with the frequency of contact e.g. there should be a progress note on the relevant care plans entered at least once each shift (morning, afternoon and nights) Community progress notes should be completed as a minimum after each contact Staff should ensure that the progress notes include: What the staff saw and heard in relation to the person s strengths and assessed needs What the staff perceived and why they perceived it in relation to the person s strengths and assessed needs Reference to the relevant element of the care plan e.g. CP1 personal care, CP3 therapeutic activity etc A record should be made in the progress notes even if the assessed needs addressed by the care plan does not occur e.g. Mr Smith has used relaxation techniques, structured activity, (painting and yoga) and conversations with staff to manage his concerns for his family and his anxiety regarding his time on the ward. Mr Smith reports that he has experienced no overt anxiety this morning and is confident that he can continue to use these strategies when he returns home Specific situational events involving complex, risky and sensitive situations which necessitate transfer of information verbally from one member of staff to another, either within or between agencies, need to be recorded under the SBAR headings i.e. Situation, Background, Assessment, Recommendations/Decisions Where a record is made in relation to Mental Capacity Act or Best Interest decisions then it should be recorded under the specific heading e.g. Mental Capacity Act with the heading underlined. This will aid identification of those decisions All records should comply with Professional standards as a minimum they should be dated, timed, signed, legible, written in black ink and include professional status NOTE: referencing the progress note to the care plan will aid tracking and evaluation of the effectiveness of the interventions set out within the care plan. Evaluation will be determined by the person s and professional s views on what s worked well, what s not worked so well and what needs to change to support recovery. This will then enable a decision to be made about whether the care plan needs to be continued, discontinued or adapted. RiO Handbook Draft V1.2-13/05/

41 Appendix 5 Mental Health Forms Presenting Situation This form is used to record the details of the presenting situation related to a particular referral. This form is in the Part 1 Referral Related group. The Referral/Admission field is a list of all valid referrals and admissions for this client/patient. You must select one to link this information to a particular event. Current Interventions Including Medication This form is used to record the details of the current interventions, including medication related to a particular referral. This form is in the Part 1 Referral Related group. The Referral/Admission field is a list of all valid referrals and admissions for this client/patient. You must select one to link this information to a particular event. Referral Outcome Decision This form is used to record the details of the outcome of a referral. This form is in the Part 1 Referral Related group. The Referral/Admission field is a list of all valid referrals and admissions for this client/patient. You must select one to link this information to a particular event. Information Sharing and Consent This form is used to record details of a client s/patient s consent to share and receive information about his or her care. This form is in the Information Sharing and Consent folder in the Part 2 Ongoing group. Updated By and Updated On are entered automatically when the form is saved. Mental Health History This form is used to record the client s/patient s mental health history. This form is in the Past (Physical & Mental Health) folder in the Part 2 Ongoing group. There is only ever one version of this form per event it can be edited as many times as necessary and changes can be made to the information it contains. A full history is retained. RiO Handbook Draft V1.2-13/05/

42 Physical Health History This form is used to record the client s/patient s physical health history. This form is in the Past (Physical & Mental Health) folder in the Part 2 Ongoing group. Personal & Social Information This form is used to record personal and social information about the client/patient. This form is in the Personal & Social Information folder in the Part 2 Ongoing group. Care Management This form is used to record information about care management issues. This form is in the Care Management folder in the Part 2 Ongoing group. Mental Health/Children s Legislation This form is used to record legislation and forensic information. This form is in the Mental Health/Children s Legislation folder in the Part 2 Ongoing group. Forensic History This form is used to record information about any forensic convictions that the client/patient may have. This form is in the Mental Health/Children s Legislation folder in the Part 2 Ongoing group. Substance & Alcohol Use This form is used to record details of the client s/patient s use of alcohol and other substances. This form is in the Substance & Alcohol Use folder in the Part 2 Ongoing group. Problematic Substance & Alcohol Use Form This form is used to record details of the client s/patient s problematic use of alcohol and other substances. This form is in the Substance & Alcohol Use folder in the Part 2 Ongoing group. RiO Handbook Draft V1.2-13/05/

43 Mental State Examination This form is used to record results of a mental state examination. This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. Physical Examination This form is used to record details of a physical examination This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. Physical Health Assessment This form is used to record details of a physical health assessment. This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. Physical Monitoring This form is used to record details of a physical monitoring. This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. Nutrition This form is used to record a client s/patient s nutritional state. This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. BMI is a calculated field, based on the height and weight entered in the two preceding fields. Total weight loss score and Total weight gain score are also calculated fields information is displayed indicating the action to be taken, if any. RiO Handbook Draft V1.2-13/05/

44 Body Map Annotations This form is used to record assessment details by annotating a body map. This form is in the Mental & Physical Health Examination folder in the Part 2 Ongoing group. This folder also contains a hyperlink to Adverse Drug Reactions/Allergies, which takes you to the RiO function for recording this information if needed. Client & Carer s Understanding of Assessment This form is used to record details of the client s and carer s understanding of assessment. This form is in the Client & Carer s Understanding of Assessment folder in the Part 2 Ongoing group. Carer 1 and Carer 2 are populated from the client s demographic record any changes need to be made there. Risk Assessment This form contains the results of a risk assessment for the client/patient. It is important to complete all areas of the form even if there is no risk of a particular type to show that every area of risk has been considered. This form is in the Risk Information folder and a link to it is present in from the Core Assessments.. Information entered into this form is displayed in the Risk Summary, accessible from the Case Record. Client HCR-20 Assessment Information displays a summary from the HCR- 20 assessment, if one exists. Formulation Summary This form is used to record details of the Formulation and Summary derived from the completed assessment. This form is in the Formulation/Summary folder in the Part 2 Ongoing group. This folder also contains a link to the client s/patient s Care Plan. Mental Health General Assessments Additional Personal Information This form is used for recording information about the referral to the Mental Health services To access this form, select Client Demographics on the right of the Case Record page. You cannot make changes to this form once it has been saved but you can create a copy and edit that version. Careplan Contact This form is used for recording information about the client s/patient s contacts for inclusion in the Care Plan. RiO Handbook Draft V1.2-13/05/

45 This form is accessed from within the client s/patient s care plan. Click the Other Information link at the bottom of the care plan and a list of three forms is displayed: Careplan Contact (this form) Careplan Distribution (see below) Crisis, Relapse and Contingency Plan (see below). Careplan Distribution This form is used for recording information about the distribution of the care plan to relevant people. This form is accessed from within the client s/patient s care plan. Click the Other Information link at the bottom of the care plan and a list of three forms is displayed: Careplan Contact (see above) Careplan Distribution (this form) Crisis, Relapse and Contingency Plan (see below). Carer s Assessment This form is used for recording information about the client in their Role as the Carer of another service user. To access this form, select Role as Carer Information on the right of the Case Record page. Court Diversion Scheme This form is used to record information where a client/patient has been referred for assessment from a court. To access this form, select Client Referrals on the right of the Case Record page. The Referral field has a search facility to identify referrals not already linked to a form of this type. Select one to link to this form. Section 117 Review Information This form is used for recording information about the Section 117 details for CPA Review meetings. To access this form, select Care Planning, CPA and Reviews on the right of the Case Record page. NOTE: Old copies of the form that was titled: CPA Review Management will also be listed in the index and can be viewed via this form. CPA review management information is now recorded within the CPA Review functionality. Crisis, Relapse and Contingency Plan This form is used for recording information about the referral to the contingency plan that is to be used if the client/patient suffers a relapse or a crisis. RiO Handbook Draft V1.2-13/05/

46 To access this form, select Care Planning, CPA and Reviews on the right of the Case Record page, then select Care Planning. This form is accessed from within the client s/patient s care plan. Click the Other Information link at the bottom of the care plan and a list of three forms is displayed: Careplan Contact (see above) Careplan Distribution (see above) Crisis, Relapse and Contingency Plan (this form). Delayed Discharge This form is used to record the reasons for delaying discharge. To access this form, select Inpatient Management on the right of the Case Record page. Police Screening Request This form is used to record information where a client/patient has been referred for assessment by the police. To access this form, select Client Referrals on the right of the Case Record page. The Referral field has a search facility to identify referrals not already linked to a form of this type. Select one to link to this form. Pre-Discharge Planning This form is used to record details of pre-discharge planning before discharge from an inpatient bed. To access this form, select Care Planning, CPA and Reviews on the right of the Case Record page. Referral Screening This form is used for recording information about the referral to the Mental Health services To access this form, select Client Referrals on the right of the Case Record page. The Referral field has a search facility to identify referrals not already linked to a form of this type. Select one to link to this form. RiO Handbook Draft V1.2-13/05/

47 Mental Health Risk Assessment HCR-20 The HCR-20 is an internationally recognised assessment for assessing the risk of violence. (Webster, Douglas, Eaves & Hart 1997). These forms should only be used by Health Care Professionals who have been trained in using the HCR-20 assessment. This is a suite of forms accessed from the Risk Information folder. Enter the date that this assessment starts in the box on the left and click Start from this date. A list of folders is displayed on the left, each containing one or more forms. HCR-20 R Factors (in the Step 1 folder) cannot be edited after it has been saved. It works in the same way as the Physical History form described in lesson CR10 Accessing Forms. MAPPA The MAPPA form is used for recording details of risk to others. This form is in the Care Planning, CPA and Reviews folder. The Inpatient Consultant field contains the name of the patient s current consultant if the patient is an inpatient. The drop-down list of client/patient contacts displayed in the Agencies Involved section lists professional contacts recorded as part of the client s/patient s demographic record. The list displays the Contact Type, First Name and Surname for each valid contact MH1 This form is used to record details of a Mental Health Act, MH1 assessment. This form is in the MHA folder. The Referral field is used to link this assessment to a valid referral. Click the search icon to display a list of referrals. Nearest Relative This form is used to record details of the nearest relative. This form is in the MHA folder. A large quantity of information is provided on the form giving guidance about how information entered into the form is interpreted. Observations This form is used to record details of observations of a client/patient and their family or carer. This form is in the Risk Information folder. Risk Assessment This form contains the results of a risk assessment for the client/patient. It is important to complete all areas of the form even if there is no risk of a particular type to show that every area of risk has been considered. RiO Handbook Draft V1.2-13/05/

48 This form is in the Risk Information folder. Information entered into this form is displayed in the Risk Summary, accessible from the Case Record. Client HCR-20 Assessment Information displays a summary from the HCR- 20 assessment, if one exists. Safeguarding Child Summary This form is used to record details of child protection assessment. This form is in the Risk Information folder. Section 117 Eligibility This form is used to record eligibility for Section 117 aftercare under the Mental Health Act. This form is in the MHA folder. Specialist Assessments: MOHO OT Assessment MOHO stands for Model of Human Occupation. If you select MOHO from Specialist Assessments in Case Record, a list of the four forms in this set is shown on the left of the page. MOHOST & OCAIRS This form is used by occupational therapists to record the outcomes of the MOHOST and OCAIRS assessments. Information on the ratings used is displayed on the form. OPHI-II This form is used by occupational therapists to record the outcomes of the OPHI-II assessment. Information on the ratings used is displayed on the form. VQ and ACIS This form is used by occupational therapists to record the outcomes of the VQ and ACIS assessments. Information on the ratings used is displayed on the form. RiO Handbook Draft V1.2-13/05/

49 WRI & WEIS This form is used by occupational therapists to record the outcomes of the WRI and WEIS assessments. Information on the ratings used is displayed on the form. Specialist Assessments: NCDS The NCDS specialist assessments consist of two forms, which are displayed on the left of the page when NCDS is selected. These forms are used to record information required for the NCDS (The National CAMHS Data Set). More information is available about the NCDS at NCDS Form This form is used to record details required for the NCDS. The Referral field is used to link this form to a valid referral for the client/patient. Click the search icon to display a list of referrals. NCDS Rating This form is used to record ratings required for the NCDS. Specialist Assessments: NDTMS The information recorded on this set of forms is used, with the demographic information recorded for the clients, to provide data for the National Drug Treatment Monitoring System (NDTMS). NDTMS - Main Capture Form This form is used to record the main details needed for the NDTMS. This form must be linked to a referral to a drug treatment service. NDTMS Adult Services Modalities This form is used to record adult services modalities information for the NDTMS. This form must be linked to a referral to a drug treatment service. RiO Handbook Draft V1.2-13/05/

50 NDTMS - TOP This form is used to record Treatment Outcome Profile (TOP) information for the NDTMS. This form must be linked to a referral to a drug treatment service. NDTMS Young People Services This form is used to record young people s services modalities information for the NDTMS. This form must be linked to a referral to a drug treatment service. Specialist Assessments: Observation/Seclusion Select Observation/Seclusion from Specialist Assessments and the three forms forming this set are displayed on the left of the page for selection. A Mark as complete (close) field is on each of the forms in this section. You can edit it as often as necessary until this field is selected and the form is saved after that although you can create a new copy of the form, you cannot change information in this one. Access to Fresh Air This form is used to record access to fresh air that has been offered to detained inpatients. The Access to Fresh Air form is for use with detained patients only. Observation This form is used to record details of observations carried out on inpatients. Seclusion This form is used to record details of the use of seclusion with inpatients. Outcome Measures HoNOS stands for Health of the Nation Outcome Scale. CGAS This form is used by Child and Adolescent Mental Health Services to record a score for general functioning. Experience of Service This form is used to record details of the client/patient s experience of service. HoNOS (Working Age Adults) This form is used to record HoNOS scores for working age adults. RiO Handbook Draft V1.2-13/05/

51 The latest score recorded on this form can be automatically entered into a CPA review record. HoNOS65+ (Older Adults) This form is used to record HoNOS scores for older adults. HoNOS-ABI This form is used to record HoNOS scores for people with acquired brain injury (ABI). HoNOSCA This form is used to record HoNOS scores for children and adolescents. There are two versions of the HoNOSC available. Current and Pre These are located in a form set menu when you click on the HoNOSCA link. HoNOS LD This form is used to record HoNOS scores for people with learning disability. HoNOS-secure (v.2) This form is used to record HoNOS scores for people held in secure accomodation. Paddington Complexity Scale This form is used by Child and Adolescent Mental Health Services, to record a score for complexity. Reference: Yates P, Garralda ME, and Higginson I. Paddington complexity scale and health of the nation outcome scales for children and adolescents. British Journal of Psychiatry 1999;174: Strengths & Difficulties This form is used by Child and Adolescent Mental Health Services, to record a score for strengths and difficulties derived from the Strength and Difficulties Questionnaire (SDQ). Reference: Developed by Robert Goodman at the Institute of Psychiatry, who owns the copyright to the SDQ. Some sections of this form contain a Total score field. This is a calculated field that gives a combined score for all fields in that particular section. RiO Handbook Draft V1.2-13/05/

52 Appendix 6 - RiO Staff Code of Practice RiO is an electronic record keeping system that ensures clinicians have the complete record of the person they are caring for in a standard format across the Trust. To realise the full benefits of RiO it is important all clinicians use RiO in the same way and as such this Code of Practice should always be followed. This document has been ratified by the Trusts Head of Professions. 1. Referrals & Patient Contact What is a recordable contact? This is largely a matter for individual judgement but a contact does not need to be recorded when very brief and does not make a material difference to the clinical care of the person using the service. How do I record requests for advice for people not known to the service and are not formal referrals e.g. consultation with a GP for advice who is not asking for the patient to be seen? This should be recorded in the Referral Screening section. A new patient episode should be opened (which takes less than a minute when using an NHS number) and appropriate detail recorded. Not all fields need to be completed. If required, a letter to the GP can be made by cut and paste into a standard letter template. Where should I record referral triaging? This should be recorded in the Referral Screening section. If the person will be assessed it is only necessary to briefly fill in the salient detail and not all fields may be needed to be completed as the referral letter will be the primary source of information. If the triager needs to contact the referrer for more information any additional information should be recorded in the appropriate field in this section. If the person is not to be assessed the reason for the decision should be recorded e.g. more appropriate for Cruse counselling and discussed with referrer who agrees. Where do I record telephone referrals? Record these in Referral Screening. Use this template to structure the information from the referrer. What information should I put into a referral to another DPT team? As the whole clinical record will be available on RiO to the team receiving the referral you only need to state the reasons for referral and desired outcome. How do I update a discharged persons record if I see them for a new assessment? You should always use create new (referral) record for each section. For some sections e.g. Substance misuse this will bring up the previous record which you should edit according to your new assessment. RiO reduces duplication in this respect. For other sections where you are not adding to history e.g. Mental State this will be blank and you will need to complete a new record. Rapid re-referrals must no longer be used. 2. Care Planning & Progress Notes Should I use HoNOS in outcome measures? RiO Handbook Draft V1.2-13/05/

53 To establish a baseline HoNOS, all existing people using the service must have a baseline HoNOS completed as soon as possible after RiO goes live. All new people using the service MUST have a HoNOS completed by either MW&A, UIC or specialist services like Workways at the first assessment. On discharge, all people using the service MUST have a HoNOS score. Some teams may decide HoNOS is a useful tool for measuring the effectiveness of their care and may wish to monitor HoNOS scores more frequently. Where do I enter rating scale results? You should enter rating scale results in the progress notes and then link this to a rating scale care plan. If you wish to review the scores you need to open the care plan and linked progress notes. The original rating scale should be scanned and the original put in confidential waste. What category should I use in care planning? This is important as progress notes are linked to categories so you can filter progress notes. You should pick the category which best reflects the care-planned need (we recognise this is not an exhaustive list and does not best reflect Recovery practice and will be working to improve). How should care plans be related to need? Individual needs should have separate care plans. In the past, each person has had a care plan with groups of interventions, however from now on each need should have a separate care plan. Taken together these care plans comprise the recovery care plan. RiO facilitates this approach. All care plans can be viewed in list form which is particularly useful for care planning meetings and ward rounds to ensure there is a discussion about all needs and how they are managed. What should I add to the progress notes rather than the core assessment? Any historical information e.g. personal, psychiatric, family should be entered into the core assessment i.e. part 1 and/or part 2 of the assessment. Progress notes should reflect the effectiveness of care plan interventions and any other important information that is not entered into another field. Which staff will need their records validated? Only students (nursing, medical, OT etc) and trainee psychologists. Volunteers are considered employees and as such have an honorary contract and will be able to validate their own notes. When should I tick This is a significant event or Add to risk history? You cannot tick both. Some events will be automatically added to one or other category e.g. AWOL or CPA review to Significant Events. There is no absolute guidance as to which to tick but if any in doubt tick Add to risk history. However, if you do tick risk it will be also added to the significant events! Should I fill in the Care Plan Contact record? Only fill in the contact details not the client leaflet distribution. When should I tick third party information? RiO Handbook Draft V1.2-13/05/

54 This is when you record any information about the person you are caring for from another person who is not from DPT. You must tick this box if the third party does not consent to that information being released to the person you are caring for. This box should also be ticked for information not about the person you are caring for but about a significant other e.g. a spouses own mental health. If I care for a person under MAPPA do I have to fill in the MAPPA fields? Yes, this is mandatory. Should I complete the Care Management section? Yes, it contains the record for accommodation, activities of daily living, finance and support network. Again the record only needs to contain details which are relevant. What does CPA Management mean? This section is about managing CPA and booking reviews and applies to all levels of recovery coordination. Where do I record discharge planning meetings and S117 reviews? There is not a single field for this within RiO but should be completed in three areas CPA Review, Crisis Relapse and Contingency Planning and Care Planning all in the Care Planning, CPA and Reviews section. A review meeting should be scheduled in the CPA Reviews field first. 3. Inpatient Do I need to complete the Pre-discharge Planning section? This is for inpatients only. All inpatients will be followed up after discharge within 7 days so both fields need to be marked yes. How will observation records work? The primary record will be on a standard paper record form which will need to be scanned into RiO. There should be an entry at the end of the shift to confirm compliance with the observation level. How will ward rounds, golden hour and care planning meetings work with RiO? Wards will have access to RiO in the ward round room. Golden hour meetings should use the ward set up. They will have projectors and screens so everyone in the meeting can see the record. 4. Physical Health Where do I record investigations done pending results e.g. blood tests? These should be recorded as a care plan in the Care Planning section to ensure that the results are reviewed. This takes about 30 seconds. What do I do with blood and x-ray results in RiO? You must record they have been viewed and add significant results and response in the progress notes. Where investigations are ongoing it is sensible to create a care plan and link progress notes to the care plan. RiO Handbook Draft V1.2-13/05/

55 Where do ECG and ECT EEG results go? These are part of the record and need to be scanned in to RiO and the original should be put in confidential waste. When should fluid intake and output, weight, temperature etc be entered? This should be entered from the paper record sheets by the end of each shift or more frequently if required by the ward clerk (preferably) and validated by the named nurse. Should I complete the Nutrition Assessment? Yes, this mandatory for inpatients and at the clinician s discretion for people in the community. What should I put in the comment box in Physical Alerts? This box will link to the national NHS spine and no clinical data should be entered at present. 5. Mental Health Act Who fills in Mental Health Client section? The admitting nurse will complete this record. Some sections e.g. S117 will only be completed later in the admission. What does LSSA mean and do I need to fill this in? It means Local Social Services Authority and this box does not need to be completed. Mental Health/Children s Legislation Do I need to fill the section about child and adult protection plans if there are no issues in this area? Yes, if this is not completed the patient screen will display unknown against child and adult protection plans so the appropriate box should be ticked. This should be answered to the best of your knowledge but you may need to check if you have any doubts. If the answer is no then no further comments will be necessary. Do I fill in the Mental Health Legislation Current section? Yes, but not for any Mental Health Act information as this is recorded elsewhere. This section is primarily to comment on e.g. Mental Capacity, Lasting Power of attorney. If a FACE form is completed it should be referenced here e.g. see FACE form and scanned into RiO. Do I fill in the Mental Health Legislation History? Yes, this is where previous Mental Health Act use is recorded which is not on RiO. 6. Forensic History Do I need to fill in Prison Reference No. and Index Offence? Only if this is relevant, which is usually when the person is under the care of Trust Secure Services. 7. Core Assessment Do I have to complete all the fields in each screen? RiO Handbook Draft V1.2-13/05/

56 No, you do not have to all sections, only relevant details should be added for a good enough assessment. Do I need to fill in the Substance and Alcohol use section? Yes, this is mandatory, including negatives for current and past history but further sections only when clinically indicated. Do not use the hyper link to NDTMS unless working within addiction services. How often should I complete the Client and Carers Understanding of Assessment? This should be completed on initial assessment and review in accordance with the recovery coordination guidelines. Do I need to fill in the Information Sharing and Consent section? Yes, this is a mandatory. You need to give the person the Trusts confidentiality leaflet and discuss confidentiality and consent to share information and record their decision specific consent in the comments box. Trust policy is that you do not have to get the persons signature. 8. Carer Assessment Should I complete the Role as carer assessment? Yes 9. Specialist Assessment Should I fill in the Specialist Assessments section? MOHO OT is for Occupational Therapy, NCDS for CAMHS, NDTMS Addictions, Observation and Seclusion for inpatient wards only. 10. Risk Assessment What do I put in the Summary box in the Risk Assessment? This box is mandatory. All staff should include a formulation of the risk and a management plan to inform the care plan and include a statement of the degree of risk. 11. Scanning What documentation should be scanned into RiO? The following should documents should be scanned: External letters e.g. from GPs, Social Services, Council etc. Recording of observation levels Medicine charts (once completed) You do not need to scan Serious Untoward Incidents and incident reports, complaints and appreciations, clinical supervision records, and blood and x-ray results. 12. General RiO Practices RiO Handbook Draft V1.2-13/05/

57 RiO encourages clinicians to be paper-light, so should I make written notes whilst seeing a person using the service? This is a matter of personal preference but if you are unable or prefer not to type your notes in to RiO during the consultation or very soon afterwards we would recommend you make brief written notes of important details. Your written notes should be shredded after use (and not scanned into the system). How soon should I complete my RiO record? We expect all community staff to complete the RiO record within 24 hours unless there is high risk when the record should be completed as soon as practicable. Inpatient staff should complete the record as soon as possible but always before the end of their shift. How detailed should my RiO record be? Clinical records should be observational, factual and free from subjective comments about the people who use our service or their relatives. Records should report relevant findings, decisions, risks, investigations, care plan, management and progress. Only salient detail which add value to the persons care should be recorded and as briefly as possible and not all boxes need to be completed. The important thing to remember is the RiO record should contain sufficient information for continuity of care i.e. if another clinician needs to see the person they will easily understand the care to date and the current care plan. Do not aim for a perfect record but one which is good enough for the purposes outlined above and for the Practice Quality Audit (PQA). Always assume that the people we are making a record about will read their clinical records at some stage. Can I ask someone else to enter RiO data for me? No, you should enter your own record. Can I use acronyms in RiO? Yes, but only the agreed DPT list of acronyms. In joint assessments who has responsibility for completing the record? There should be an agreement between the clinicians who enters the record but the other clinician can log on and add any additional relevant detail as well, which is recorded as their assessment in the Mental Health History. Should I save my record as I go? Yes, there is a time-out function of 30 minutes after the last entry and if you do not save the record it will be lost. This is particularly important if you get called away from the system. Should I fill in the experience of service in outcome measures? No, we will have a separate system for this purpose. Do I have to use the RiO diary to book my appointments? For community staff, yes, this is how contacts are collected. You should not book appointments for other clinicians without their permission at this stage until this has been piloted. For in-patient staff, it is not necessary to use the diary for contacts. RiO Handbook Draft V1.2-13/05/

58 What will happen if I feel that I am being asked to fill in records which do not add value to care and take too much time? We would like to hear from you as we will be updating the Code of Practice according to clinician s experience. Please your comments to dpn-tr.rio@nhs.net My typing skills are poor, how can I improve? An online keyboard skills tutorial can be found on the RiO Blog and using this tutorial for a few minutes each day will significantly improve your skills. ACRONYMS (also available for access to records) AWOL Absent without leave CAMHS Child and Adult Mental Health Service DAS Depression and Anxiety Service DPT Devon Partnership Trust ENDAS Exeter and North Drug and Alcohol Service EI Early Intervention ED Eating Disorders GP General Practitioner HoNOS Health of the Nation Outcome Scale HCP Health Care Professional LD Learning Disability MW&A Mental Wellbeing and Access OPMH- Older Peoples Mental Health R&IL Recovery and Independent Living UIC Urgent and Inpatient Care RiO Handbook Draft V1.2-13/05/

59 Appendix 7 - RiO Guide to using ICD-10 What is a diagnosis? In medicine, diagnosis (meaning to distinguish from the Greek) is a method of grouping characteristic elements of the person s history together with signs, symptoms and investigations. Why are diagnoses important? All people using our service are required to have a diagnosis or working diagnosis as part of the NHS minimum data set. Our commissioners also expect people who use our services to receive care which is recovery based thorough broad understanding of their illness and personal circumstances. Diagnosis is one element of this and is central to the application of a great deal of evidence based care eg NICE guidance. Many people who use our services wish to have a diagnosis to help them to understand what has happened to them and to find appropriate information and support eg in dementia care one of the major criticisms for people with the condition is that they either do not receive or have a diagnosis very late in the condition. In addition, we need to understand the needs of people referred to the Trust to be able to plan clinical capacity and when we wish to commission a new or more of a service. Currently, the Trust often struggles to make as robust case for resources as it could against non-mental health organisations that routinely collect diagnostic data. What is a working diagnosis? Frequently it is not possible to make a firm diagnosis, especially in new presentations. A working diagnosis recognises this uncertainty. Should I be concerned that making a diagnosis may harm the people we care for? Many clinicians are understandably concerned that diagnosis is a label which may actually do more harm than good in a person s recovery, for instance by increasing stigma. Although, all people using our services will be required to have a diagnosis or working diagnosis we should remember that it only describes some of their needs and we should make sure others do not generalise from the diagnosis for instance by describing someone as schizophrenic. What is ICD-10? ICD-10 is the World Health Organisation International Standard Diagnostic Classification for coding diseases and provides a diagnostic framework to facilitate more accurate and consistent diagnosis. An online version is available at ; and hyperlinks to each category in the RiO help file. Can I make an ICD-10 diagnosis or working diagnosis? All psychiatrists are trained to use ICD-10. All psychologists and other clinicians above Band 6 are able to make a diagnosis or working diagnosis. It should be recognised that in all healthcare settings, clinical diagnoses are necessarily a clinician s opinion. They may not therefore be absolute and clinical opinions may differ. What training is available? The World Health Organisation has an online training package at; click on ICD-10 Training Tool. How do I make a diagnosis or working diagnosis? Chapter V (out of 21 chapters) contains the diagnostic categories for Mental Health which are prefixed with F eg F21.0. The first number or primary code denotes the overall condition and the RiO Handbook Draft V1.2-13/05/

60 next number the secondary presentation eg Manic episode primary code = F30, and with psychotic symptoms = F30.2. You are allowed to record just the primary code. To make an ICD-10 diagnosis compare the clinical assessment to the general description, guidelines for making a diagnosis, exclusion criteria and lists of commonly used synonyms eg grief reaction (would be coded in F43.2 Adjustment Reaction). Follow any cross referencing if necessary. Further guidance can be found at; What if I do not feel confident about making a particular diagnosis or working diagnosis? If you do not feel confident about making a diagnosis or working diagnosis you should discuss it with the team psychiatrist. RiO Handbook Draft V1.2-13/05/

61 Appendix 8 - Registering a Carer on RiO & Linking the Carer to a Client Key Information An individual may be registered as a carer if they are responsible for a client s care but are not actually being seen as a client themselves. Carers are those who have taken responsibility for looking after the needs of another individual, as defined by the Carer (Recognition and Services) Act A carer must be locally registered on RiO before appointments can be booked with them. A carer must be locally registered on RiO before details can be recorded of whether the Carer s Assessment has been offered. This information must be recorded for all carers. A maximum of two carers can be linked to any one client in RiO. Searching for and Registering a Carer on RiO Step 1. From the Client Record menu, click Case Record. The Search page is displayed. Step 2. In the bottom half of the screen, enter information about the carer into at least two of the following fields (preferably Family Name + Given Name + DOB). Family Name Given Name Gender First line of address Postcode Date of Birth RiO Handbook Draft V1.2-13/05/