Guide to standard for Record Keeping and Rio process Liaison Psychiatry

This guidance is intended for clinicians working for KMPT Liaison Psychiatry Services including staff working out of hours. It gives details of how to access and complete appropriate Rio documentation.

All records on Rio must adhere to the standards set out in Health and Social Care Records Policy (KMPT.CliG.071.03)Also refer toLiaison Rio Documentation – Scenarios and Requirements’

  1. REGISTER AND SYNCHRONISE NATIONAL AND LOCAL RECORDS

This can be done by team secretaries in EK, Medway and Dartford however will need to be completed by the liaison clinician in Maidstone and Pembury.

Demographics field must be fully completed and include Ethnicity, Nationality, Religion and Disability

  1. REFERRAL FORM:

Search client, put in access reason and this will take you to case record. From the hyperlink on the right hand side, choose ‘Client Referrals’, ‘Entry/Exit’ and ‘create new Referral’

  • In hourscompleted by liaison clinicians or team secretary
  • Out of hours completed by liaison clinician

Referral initiated date: Date of referral.

Service Group:Liaison Psychiatry

Service: Liaison Psychiatry

Care Setting:Community

Referral Source:Accident & Emergency or ‘Other’ if a ward.

Referrer: A&E dept or name of ward andhospital name i.e. Pembury/Maidstone/ DVH/Medway/WHH/QEQM/KCH

Referral Reason:Assessment

Team referred: East/Medway/Dartford/Maidstone & SW Kent.

HCP:leave blank

Referral Urgency:Urgent for A&E, Routine or Urgent for anywards dependent on needs.

Administrative Category:leave blank

Referral Comment:completed in hours by Team secretaries/liaison cliniciansout of hours clinicians complete. Note information needs to be exact information from urgent request form including consent and if medical intervention in A&E required. In EK add the SMART rating

Date & time referral received: Date and time of referralmade. Ensure that you complete the time in 24 hour clock otherwise it defaults to 00:00 and response time will breach

Referral Accepted Date:same date as referral date for all urgent referrals

next working date for any routine referrals made out of hours

  1. DOCUMENTS FOR LIAISON

a) PROGRESS NOTE All progress notes need to start with:

“Liaison Psychiatry and the time thepatient was seen and not the entry time to the record

“Ax in A&E/ward at …..Hospital (see Core Ax) or Reviewed in A&E/ward at …….Hospital”

Do not cut and paste from core ax

Reviews are recorded here

All notes need to be validated for students

For self harm incidentscheck that the significant event box at the bottom of the progress notes is ticked. Significant events can be viewed as follows: from case record click on Client Related Data view, Significant event

b) Core Assessment:

-Presenting Situation and Referral

-Mental Health history

-Physical health history

-Personal and family history

-Social history

-Mental health legislation

-Forensic

-Substance and Alcohol use (Liaison substance misuse screening score and intervention)

-MSE

-Formulation/Summary to be completed on discharge from Liaison

c) Risk Assessment

d) Safeguarding ChildrenEVEN IF NO ACCESS TO CHILDREN and/or Adult Client form

located under risk information

e) Social Inclusion

f) Information Sharing and Consentlocated in ‘MCA and Information Sharing and Consent

Record “consent given yes” or “consent given no” and then reasons why

g) Allergies – on patients case record screen.

h) Generic Closure Summarylocated in ’Clinical Information’ on patients case record and only to be completed on discharge from Liaison. The summary should be completed by the liaison clinician when the patient is discharged by liaison and/ or mentalhealth intervention in the general hospital is completed ie MHA ax/mental health unit admission

From the Case Record screen of the patient, select ‘Clinical Information’, then ‘Editable Letters’. Choose Generic Closure Summary from the drop down menu of ‘letter type’. Once this has been completed, click on the ‘send to Rio’ button on the top left hand side. ** If this button is not available/not workingsave the summary to the shared drive (S). From the ‘Clinical Information’ link on the case record screen, select ‘upload document’ and in top field click on ‘browse’ and locate document from your S drive and press ‘open’. Complete the following fields as followed:

Author: Name of assessor

Document Title: EK Liaison Psychiatry Service/Discharge

Date:

Type: Select ‘Discharge Summaries’ from drop down menu.

Ensure that you delete the copy of the summary from the shared drive.

  1. DIARY (all contact including phone calls etc to be entered and appointments must be outcomedwithin 24 hours of appointment as will not count towards KPIs or qualify for payment under PbR)

Book appointment

Appointment types choose:and includes both telephone contact with other clinicians and face to face contacts

- First appointment

- Follow up appointment

-Telephone contact

Location: Hospital Site

Intended Duration: time taken of all clinical activity with patient.

Outcome appointment:

Actual duration:duration of clinical activity (all activity from checking Rio for background and liaison work and face to facecontact however not to include time of writing information on Rio documentation)

Seen Time:Start time of any Liaison work regarding patient (background checks, phone calls etc and isnot the entry time to the record

Outcomeschoose from the list below:

** Please note that if attended ward/department however patient not seen due to walk out/self discharge/at xray etc still choose from the first 4 optionsdepending which of the last words is relevant

-Attended/seen/ discharge: assessment only or follow up by primary care

- Attended/ seen/ follow up appointment needed:liaison/ CRHT/ CMHT/CMHTOPS/for review

-Attended/ seen / MHA assessment

- Attended/ seen / referred for admission: to Mental Health Unit

- Telephone contact – discharge

- Telephone contact – follow up appointment needed

- Telephone contact – MHA Assessment

- Telephone contact – referred for admission

  1. DISCHARGEto be completed by liaison clinicians

From case record click on Client referral, Entry/ Exit, this will open the referral screen, click in green button of referral, this will open the Discharge referral screen, complete following fields:

Discharge Date: date patient was discharged from Liaison Psychiatry

Discharge HCP: Your name

Discharge Reason:

- Discharged on professional advice

- Discharged against professional advice:

- Patient Died

-PATIENT Non-attendance: if patient has been discharged prior to Liaison attending or has self-discharged

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Updated November 2012 KS 2