Care Planning in RiO
This presentation will take you through
the process of adding a care plan to
RiO, editing it and using the CPA
functions.
• Review of individual care plan elements
should be recorded in the progress notes
and these notes MUST be linked to the
relevant care plan
• Any element of the care plan can be
updated or changed to reflect changes in
assessed need/ required intervention
• Interventions that have been completed
must be closed with a finish date added.
• Care plans elements can be ordered by
clicking on ‘Order’ in the care planning
screen, highlighting the care plan you want
to move and using the arrows to move it.
Click save before closing the pop up
window.
• Care plans can be recycled/ re-opened by
clicking on ‘Display Old’ in the care
planning screen and then clicking on the
recycle symbol.
Click Here
Click here
Click here
Describe what the issue/ assessed need is and why you are taking
action. If two issues are closely linked they can both be described in
the same box.
Select the most appropriate label from
the list
Click save
Your description appears here
Add further descriptions and select the
appropriate labels as required
Click here to return to the care planning
screen
Click here to highlight
Click here to edit the description
Click here to display and recycle
previous care plan elements
Click here to add an
intervention / goal
Click here to order the
care plan elements
Describe the intervention here – 1
intervention per box
Select the main person
responsible for carrying out the
intervention from this list
Describe the intended outcome
here
Select the most appropriate
intervention type
Enter the start date here
Click save
Additional interventions for this care plan can be added now or at a later date.
You can edit the care plan
by clicking here
You can view the edits
by clicking here
Click here to access
library care plans
This is the Care
Plan library
search screen
Enter the title of
the care plan you
are searching for
here
Click here
Select the care plan you want from the drop down list – if
you are not certain of the title of the care plan you are
looking for, enter * in the search text box to see the full list.
Click GO
The library care plan is displayed. Tick this box to select the
interventions required (there may be more than one available)
Click Save to pull the care plan
through to the person’s record
The library care plan can be selected
and then edited as appropriate
This library care plan is used for reporting
purposes to identify who is on the different
levels of Recovery co-ordination.
This care plan must be entered by the
responsible Clinician /Consultant – this is
the equivalent of their signature.
Scroll down
to see all the
available
interventions
you can
select
From Devon Partnership Trust Practice Standards:
The personal recovery plan will:
• wherever possible, be developed collaboratively with the person and any
others they wish to be involved. The plan will record who has contributed to
it and their agreement with the content.
• be strengths based, identifying and building on the person’s resources and
previous coping skills and strategies.
• identify who will be responsible for administration and monitoring any
prescribed medication. The arrangements for the delivery, administration
and monitoring of medication will be in accordance with the current standard
operating procedures.
• demonstrate that preferences and cultural needs have been identified and
responded to. The use of advanced statements will be encouraged.
• include arrangements for the maintenance of safety. This will include how
safety will be maintained if the recommended service is not immediately
available (eg when a person is placed on a waiting list).
• identify the care; treatment and support required to meet the person’s needs
and desired outcomes: how these will be provided and who is responsible
for each element of care.
• There will be a contingency plan which will give details of who should be
contacted in the case of concerns about the person or about the delivery of
any aspect of care. It will include the preferred response to crisis or urgent
need. The use of advance statements will be encouraged.
Risk management plans are embedded into care plans and contingency plans
are in the Crisis, Relapse & Contingency Plan in RiO.
Recovery and RIO
RiO uses words like ‘problem’ etc in the care planning process.
But…..
• Care and its planning should be focussed on the process of change
defined by the person for themselves.
• If the practitioner is to play their part in the person’s recovery journey
professionally, they need to plan and evaluate properly.
Recovery has been defined as:
• ‘A deeply personal, unique process of changing one’s attitudes,
values, feelings, goals, skills and/or roles. It is a way of living a
satisfying, hopeful and contributing life, even with limitations caused
by the illness. Recovery involves the development of new meaning
and purpose in one’s life’ (Anthony, 1993)
How many care plans (problems/needs) should
someone have?
• The number of care plans some one needs, will be
dependant on their assessed needs. When this has
been reviewed and considered by clinicians to date,
most clinicians suggest that when the number of
problems/needs in the care plan goes above 5-6 (main
problem/needs) it is worth considering reviewing this
person within an MDT format to discuss the focus of the
care plan /treatment.
• In terms of intervention/actions, again, when this goes
above 5-6 per problem/need - consider how workable
the care plan is.
Sharing the care plans
• Once the care plans have been written these should be
printed off; select ‘printable care plan’. The relevant part
of this form can be copied and pasted into a word
document and given to the person to review and
agree/discuss (This means not having to give someone
a form full of empty boxes).
• For inpatients, it is possible to print the Inpatient care
plan from the Client Related Data View – this will only
print care plans that have been added or modified since
the admission.
• The care plan distribution form is used to indicate who
has had a copy of the care plan including the person
themselves and this is where the figures on people
getting or being offered a copy of their care plan are
drawn from.
Care plan reviews
• Reviews of care plans should be documented in the
progress notes (See Best Practice and Consistency of
Recording in RiO documents for details) except in the
case of CPA reviews which must be carried out using the
CPA functions in RiO. E.g. scheduling and outcoming a
CPA review. When you outcome the CPA review, you
complete the form regarding what has worked well etc.
and this is pulled through to the printable care plan.
• If the care plan remains relevant, document this.
• If the interventions/problem/need requires updating,
review the care plan and make the relevant changes.
Who is responsible for care
planning?
• The person who is carrying out the intervention with the individual is
responsible for ensuring a care plans is in place for the intervention.
• E.g.- if a person is prescribed anti psychotic medication- it is the
prescriber’s responsibility to ensure a care plan is in place to monitor
for side effects and efficacy.
• As a general rule it makes sense for one person within the MDT to
have overall responsibility for ensuring care plans are holistic and
‘workable’ for each individual.
• In community services the Recovery Coordinator is responsible for
overall maintenance and review of care plans.
• In Inpatient services the named nurse/nursing team (ward manger)
are responsible for the overall maintenance of care plans. The
weekly MDT meetings are responsible for ensuring the care plan
(treatment plan) is reviewed.