RiO Standard Operating Procedures
F Assessment:
Contents
F Assessment:................................................................................................................................................................... 1
Initial/Ongoing Assessment Including Risk. .................................................................................................................. 1
1. Information Sharing & Consent ................................................................................................................................. 2
2. Core Assessment...................................................................................................................................................... 2
3. Risk Assessment ...................................................................................................................................................... 4
4. Specialist Assessment .............................................................................................................................................. 6
5. Social Inclusion – Accommodation and Employment Status ................................................................................... 7
F1 Capacity Assessment .................................................................................................................................................. 8
1. General Guidance and References .......................................................................................................................... 8
2. MCA Form Completion Guidance ............................................................................................................................. 9
Advance Decisions and Statements form ................................................................................................................ 9
Best Interest Considerations .................................................................................................................................... 9
Capacity Assessment ............................................................................................................................................. 10
Capacity Contacts .................................................................................................................................................. 10
Deprivation of Liberty.............................................................................................................................................. 10
Recording in other areas of the record. .................................................................................................................. 12
Initial/Ongoing Assessment Including Risk.
It is important to use the assessment functions within RiO in order to build a history and to ensure that
assessment information does not get lost in progress notes. There are a number of assessment forms in
RiO and the point at which they are completed/ re-done will depend on the individual situation. However,
there are some aspects of the assessment that must be completed on first contact within DPT for a
particular individual for clinical and quality monitoring purposes. For specific guidance on which forms
should be completed and when for each type of team, please see the Best Practice and Consistency of
Recording in RiO documents on the Intranet or via the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
It is important that assessment information is recorded consistently in these forms and not in letters or other
communications – consistency in where information is recorded ensures it can be found easily and quickly
in a crisis situation and will minimise the potential for risk.
It is essential that we routinely record whether people we see are parents/carers as part of an initial
core assessment. This is a national and local requirement and is a ‘must do’. See the Safeguarding
section for details on recording dependant children in RiO and the use of the Safeguarding Forms.
Routine Enquiry regarding abuse should also be asked at initial assessment (and recorded in the
Personal & Family History form) unless there is a clear clinical reason for not doing so which
should be recorded. It is important to identify any form of abuse, past or present, including
domestic, sexual, emotional and physical abuse.
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Many informal assessments are carried out on every contact e.g. has there been a change to risk, capacity,
mental state and the current picture will be recorded in the progress notes with the Core Assessment, Risk
Assessment and Capacity Assessment updated/ completed if required. With regard to capacity to
engage in treatment / intervention, if this is assessed as not being present then the legal basis for
intervention needs to be considered. (MHA, MCA)
When booking or recording the outcome of an appointment that involved an assessment, it is important to
select the relevant appointment type. ‘New Patient Assessment’ should be used to indicate the first
assessment following the receipt of a referral. Initial Assessment should be selected as the activity before
outcoming the appointment.
1. Information Sharing & Consent
This is generally completed at initial contact with DPT. There is an adapted version of the form on the
Consistency & Best Practice section of the RiO pages of the Intranet (see link above) and this should be
used with the person.
Where on RiO
Guidance
MCA &
Information
Sharing and
Consent
This should be completed for everyone at the first point of contact with Devon
Partnership Trust by whichever team has this contact. A paper copy should be
signed, scanned and uploaded to RiO.
The information entered in the form on RiO will be pulled through to the printable
Care Plan/CPA review.
If it would be detrimental to the therapeutic relationship and/or the person does
not have capacity to complete this at initial assessment, the HCP must note on
RiO ‘not clinically acceptable to complete at present’ and update the form at the
earliest opportunity. Where this is on the grounds of capacity the details of this
assessment should be recorded in RiO.
This form should also be used to record people’s preferences or requirements in
terms of how they are communicated with e.g. no post to home address/ letters
to correspondence address (which should be added to the addresses in the
demographics – See Section B), large font required, no phone calls to home
landline etc.
If use of the secure envelope has been authorised, this should be referred
to within this form.
2. Core Assessment
How much of this should be completed, by which team and when is detailed in the Best Practice and
Consistency of Recording in RiO Documents available in the RiO pages of the Intranet or via the link below.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
The Core Assessment Overview can be used to view all assessment related information and the overview
point in time allows you to select a date and view the content of the Core Assessment on that date.
During a single episode of care, the current assessment should be added to by editing (e.g. during an
inpatient stay or during a period of care co-ordination) – indicating in the text when and by who the addition
was made. There is no specific guidance on who completes which bit of the core assessment but it is likely
that forms such as Physical Examination will be completed by medical staff during inpatient stays for
example.
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Where information is being copied and pasted into the Core Assessment from previous documents held
either in paper notes or ePex, the source of this information, the date it was written and author should be
indicated at the top of the text. E.g. From Oak Ward Discharge Summary 12/05/09 by Dr Jones.
Core Assessments should be reviewed every 6 months as a minimum and updated as appropriate.
This includes Formulation and Risk Assessment.
When someone returns to DPT after previously being discharged, you should always use ‘create new’ in
the assessment forms (except Mental Health History & Physical Health History which are always added to).
For most forms this will bring through the text from the previous version 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.
Where on RiO
Guidance
Core Assessment
Clinically relevant information should be recorded in the appropriate part of
the Core Assessment. Not all boxes need to be completed for all cases; the
exact content of the Core Assessment will depend on the individual
presentation and the scope of the assessment.
Create New for each referral. Used to record the presenting situation and
current interventions. Only the medication the person is currently taking at
the time of referral should be recorded along with the sources it was checked
with – it is essential that this is recorded here and not in the progress notes
for ease of access and (where the assessment leads to admission) for
reporting on the CQUIN target regarding medicines reconciliation.
Presenting Situation
& Referral Outcome
Decision
Mental Health
Legislation /
Protection of
Vulnerable Adults
This is an ‘add to’ form and would only be created new at first presentation
to DPT and then added to as required.
This is an ‘add to’ form and would only be created new at first presentation
to DPT and then added to as required.
The Personal & Family History form contains the routine enquiry regarding
abuse and this should be recorded here. Family details regarding children or
dependant adults should be recorded here.
This form should be created new for each referral from an external
source to DPT and should then be added to by editing current.
This form contains the first level of safeguarding children information in that it
asks if additional support is required to parent children. This form should be
created new for each referral from an external source to DPT and
should then be added to by editing current.
More details of its use in Safeguarding Vulnerable Adults & Children section
of the SOPs.
This form should be created new for each referral from an external
source to DPT and should then be added to by editing current.
Forensic &
Probation History
This form should be created new for each referral from an external
source to DPT and should then be added to by editing current.
Substance and
Alcohol Use
This form should be created new for each referral from an external
source to DPT and should then be added to by editing current.
Problematic
Substance & Alcohol
This form is only used when problematic substance and alcohol use has
been identified.
Mental Health
History
Physical Health
History
Personal & Family
History
Social History/ Care
Management
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Use
Mental State
Examination
Physical
Examination
Physical Health
Assessment
Physical Monitoring
Nutrition
Body Map
Annotation
Client and Carers
understanding of
assessment
Formulation/
Summary
This form should be created new for each referral from an external
source to DPT and should then be added to by editing current.
Always create new. This should be completed on initial assessment and at
each review point as a minimum. Include the outcome of relevant
assessments such as MMSE or ACE-R.
Always create new. This should be completed within 24 hrs of admission
and VTE assessment should be recorded in the ‘any other’ text box with a
description of the outcome of the assessment and the code **VTE1**.
Always create new. Include the result of other relevant assessments such
as the Waterlow and Falls assessment.
Relevant monitoring information must be recorded in here and can be used
to generate a chart of information over time. O2 Sats should be recorded in
the Respiration box on this form. Always create new.
Always create new.
Always create new.
Create new for each assessment as this is relates to a specific assessment.
Create New. Formulation/Summary is a brief overview of the assessment
and will help structure your Care Plan interventions. Link provided on the
form to the Care Plan. Include results from measures such as GAD-7 &
PHQ-9 etc. which support the formulation process.
Following initial assessment (e.g. by MWA) an outline plan can be included
here and the text copied and pasted into the letter to the person/referrer.
There may be a number of current formulations relating to contact with
different services within DPT.
3. Risk Assessment
It is very important that clinical risk information is recorded in the correct place on RiO, i.e. within the Risk
Assessment Form that can be found in the Case Record, Risk Information folder.
The current risk assessment should be reviewed and added to providing changes in risk are recorded in the
appropriate text box and the appropriate button selected – not simply entered in the summary box.
Changes should be dated and the name of the assessor entered. Risk assessments must be reviewed
every 6 months as a minimum and a new Risk Assessment form created which pulls through text
from the previous form which can be edited. Where the person moves from one service to another e.g.
from inpatients to community, the risk assessment must be reviewed and summarised prior to the transfer.
The previous version of the form will remain viewable in the history.
Latest Risk Information can be viewed quickly from the link on the front of the case record. This will
show both the Risk Assessment and any progress notes that have been linked to Risk.
Where staff are concerned that someone poses an immediate threat to the public or specific
individuals and they believe that there may be further information held by police or probation, they
should seek advice from the MAPPA lead or the guidance available at:
http://nww.devonpartnership.nhs.uk/default.asp?a=11522&m=0
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Assessment
Where to find in
RiO (folder name)
Notes
Risk
Assessment
Risk Information
To be completed for all relevant people who use our
services in line with Policy.
Safeguarding adults and children issues can be identified in
the risk assessment, either with the person identified as
vulnerable or the victim, or as the perpetrator or likely
perpetrator. See Safeguarding Section.
When completing the risk assessment form:
Selecting ‘yes’ = there is a risk
Selecting ‘no’ = there is no risk
Leaving blank = the risk has not been assessed – the
reason for this should be given in the text box and any
actions to be taken in this regard recorded within the Risk
Summary.
Where someone is identified as a MAPPA nominal, it is
essential that the MAPPA box is ticked and any boxes
relevant to the offending/ risk history are ticked. The
supporting comments should include reference to any
documents or other information on the system e.g. MAPPA
minutes.
Ticking boxes is not sufficient for identifying assessed risk.
Supporting comments must always be added in the
relevant free text box.
Care should be taken when recording risk information from
a third party whose information requires sensitive handling
in the event of an access to records request. Where
information is from a third party, this should be noted in
the appropriate free text comments box.
The “Summary” of the Risk Assessment should provide a
working understanding of someone’s key risks.
1. What are main ‘live’ risks (including statement re:
likelihood and level of risk)
2. What increases the risk? (precipitating factors)
3. What are the ‘historical’ or residual risks?
4. What is the plan to reduce and/or manage the current
risk?
The overall management of risk is taken into account in
Care Planning and the review of these should be recorded
in the progress notes, linked to the relevant Care Plan. The
summary should also identify areas where further risk
assessment is required as risk is currently unknown and
how this will be addressed.
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Safeguarding
Forms
Risk Information
See Safeguarding section for details.
Risk incidents
Risk information
HCR-20
Risk Information
Observations
Risk Information
DO NOT USE - Risk incidents should be reported using the
Trust Incident Reporting system and clinical information
relating to the incident should be recorded in the progress
notes and linked to risk. This should prompt a review of the
current risk assessment and Care Plan to ensure that they
remain appropriate.
This is specific to Forensic Services and should be
completed prior to discharge as a minimum.
This is a children’s services form and should NOT be
used. The Adult Mental Health observation and seclusion
forms are under the specialist assessment heading - see
below.
The Risk Information folder also contains the Child Safeguarding forms. The Safeguarding section
of the SOPs gives specific guidance on the use of these forms.
4. Specialist Assessment
The grid below identifies when and by whom these should be used. Two of the forms are not to be used
within DPT at present.
Specialist Assessment
Guidance
MOHO OT Assessment
Includes:
These should only be completed by appropriately trained Occupational
Therapists as required. Always create new.
-
ACIS
MOHOST
OCAIRS
Occupational Self
Assessment (OSA)
Summary
- OPHI-II
- VQ
- WEIS
- WRI
NCDS
NDTMS
Observation/Seclusion
Includes:
- Access to Fresh Air
- Observation
- Seclusion
Will be visible but not to be used as it is related to Children’s’ Services
(currently out of scope).
Will be visible but not to be used as it is related to specialist Substance
Misuse services (currently out of scope). Use the substance misuse forms in
the core assessment to record issues in this area.
None of these forms are in use. See p 24
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5. Social Inclusion – Accommodation and Employment Status
These items form part of the National Reporting Indicators, PSA 16 ‘Increase the proportion of socially
excluded adults in settled accommodation and employment, education or training’ and KPI 186 & 187, and
must be completed for every person accepted for a service. This should be completed and updated i.e. at
initial assessment, formal reviews or when updates are known but a new form should be created at least
annually.
Item
Guidance
To be
completed
on RiO
Settled
Accommodation
Indicator
Select the most appropriate option from the drop down list
Yes
Accommodation
Status
Select the most appropriate option from the drop down list
Yes
Employment
Status
Select the most appropriate option from the drop down list and
complete the rest of the form as appropriate.
Yes
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F1 Capacity Assessment
1. General Guidance and References
All of these forms are found in the MCA & Information Sharing & Consent folder on the right of the case
record. This guidance relates to recording in RiO, for guidance on assessment, responding to advance
directives etc you must refer to DPT policies C24 Advance Decisions and DPT Policy M07 Mental
Capacity Act (including Deprivation of Liberty). The Best Interest and Capacity Assessment forms will only
be used to indicate that a complete Capacity Assessment including Best Interest decision has been
recorded on the pro forma and uploaded to Clinical Documents in the case record. The same is true for the
Deprivation of Liberty Safeguards form. All of the rest of the forms should be used in full. Specific guidance
for the completion of each form is below. The Capacity Assessment form can be found on the intranet
under policies and procedures, M07 Mental Capacity Act or by following the link below:
http://www.devonpartnership.nhs.uk/PublicationsLibrary.24.0.html?&no_cache=1&task=show&uid=797&cHash=611ad9296255500761b84efff67fd01a
Capacity is assumed unless there is evidence to indicate that it may be lacking in which case a
specific assessment of capacity should be undertaken.
Capacity to make decisions is specific to the decision in question at the time that the decision needs to be
made. The capacity assessment form must be completed for any ‘serious’ medical decision (i.e. life
changing treatment – see the Trust policy detailed below) and any admission to hospital or residential care
for longer than 28 days. Day to day decisions should be recorded in progress notes and be represented in
care plans. Informal assessments of capacity are part of clinical contact as much as informal risk
assessment and might include assessing someone’s capacity to engage in treatment/ intervention.
Trust Policies must be adhered to in relation to recording, acting on or disregarding advance
decisions / statements and assessments carried out under the Mental Capacity Act including
decisions arising from this. These also provide guidance on the relationship between Advance
Decisions, the Mental Capacity Act and the Mental Health Act.
There is a Mental Capacity Act link on the right hand side of the home page of the Intranet which
takes you to all the Trust guidance regarding this (see below).
Link to M07: http://nww.devonpartnership.nhs.uk/default.asp?a=8294&m=0
Link to C24: http://nww.devonpartnership.nhs.uk/default.asp?a=8427&m=0
Further guidance on applying the Mental Capacity Act can be found in the Code of Practice.
Link to Code of Practice: http://www.publicguardian.gov.uk/mca/code-of-practice.htm
Link to Mental Capacity Act page on the intranet:
http://nww.devonpartnership.nhs.uk/default.asp?a=11359&m=0
Case studies regarding the use of the Mental Capacity Act can be found on the Devon County Council
website:
http://www.devon.gov.uk/index/socialcarehealth/adult-protection/mentalcapacityact/mca-practice-guidance/mcapg31.htm
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2. MCA Form Completion Guidance
Advance Decisions and Statements
form
(If required, this form can be used to record that the question regarding advance decisions has been asked
but the person has not identified any actions or preferences they wish to record)
Item
General Guidance
Date of
Assessment
Life sustaining
treatment
Other Decisions
Written
Where is it held?
Date Advance
decision was
made
Contents of
advance decision/
Statement
Date the Advance
Decision became
invalid
Guidance
It is important to record information here as it will be readily accessible to assist in
best interest assessments should the individual lack capacity at any point and can be
used by involved clinicians to inform their work. Where the decision has been written
by the person as a separate document (best practice) it should be scanned and
uploaded to RiO with the document type ‘Advance Directives’ (advance decisions)
selected from the drop down list on the document upload screen. An advance
decision to refuse life sustaining treatment, must meet the legal criteria, i.e. it must be
signed, witnessed and be clearly related to a particular treatment and disorder. WRAP
and Contingency plans would also be referred to in this form.
The terms ‘advanced statement’ and ‘advanced decision’ are often used
interchangeably. They do, however, have different meanings. An ‘advanced decision’
relates solely to the refusal of treatment. Unlike an ‘advance statement’, an ‘advance
decision’ has the potential to be legally binding (Policy C24 Advance Statements).
Enter the date on which the Advance Directive was discussed/ identified
Select the appropriate option from the drop down list
Select the appropriate option from the drop down list
Select the appropriate option from the drop down list
Detail of who holds a formal, written Advance decision document
Enter if known
Brief summary of document content and detail of the document title if uploaded to
Clinical Documentation. Where the advance decision is a statement rather than a
document, full details should be recorded in here including any witnesses to the
statement and the circumstances under which it was made. The content of this should
be confirmed by the person making the statement and where possible a signed copy
of the statement uploaded to RiO.
This should only be completed if the person changes their decision, decides to
withdraw it or update it. Where a new decision is made, a new form should be
completed and the new document scanned and uploaded.
Best Interest Considerations
The Best Interest Decision making process is incorporated in the DPT M07 Joint Assessment form (see link
above) which should be completed electronically, saved to a network drive and then uploaded to the case
record in clinical documentation as document type Mental Capacity Act. The RiO naming convention should
be followed. Once the document has been uploaded to RiO, the version saved on the network drive MUST
be deleted.
The RiO form is then completed as indicated below in order to indicate that these considerations have been
made and where the detail is recorded.
Item
Guidance
Date of
Enter the date that the Best Interest Decision was made.
Assessment
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Best Interest
Considerations’
Reference the uploaded document
Capacity Assessment
The full Capacity Assessment process is recorded on the DPT M07 Joint Assessment form (see link above)
and uploaded to the case record (see above). The Capacity Assessment form in RiO MUST be used in
order to indicate that a capacity assessment has been carried out but only the following needs to be
recorded in this form:
Item
Guidance
Date of
Enter the date that capacity assessment was carried out.
Assessment
Decision Related to Brief outline of the decision in relation to which the capacity assessment is being
carried out
Does the Client
Choose yes or no.
Lack Capacity
If yes, what was
Refer to the uploaded document including the date of the document and the document
the decision?
title. Briefly outline the decision made in this, e.g.
It was decided to go ahead with Mary’s blood tests in the interests of her physical
health. See uploaded document RILEDevEx Capacity Assessment dated 12/09/11.
(RILEDevEx= Recovery & Independent Living, East Devon, Exmouth.- a list of team
abbreviations is in Section M, RiO Documentation)
No other part of this form need be completed.
Capacity Contacts
Item
Guidance
This should only be completed where an Independent Mental Capacity Advocate,
Lasting or Enduring Power of Attorney or a Court Appointed Deputy are involved
Deprivation of Liberty
The DoLS office at Devon County Council must be contacted to initiate Deprivation of Liberty Safeguards
Assessments and the Mental Health Act Office in DPT must be informed. They hold the record and DCC
provide or deny the required authorisation. Any forms sent or authorisations received would be scanned
and uploaded by the Mental Health Act Office using the RiO naming convention for the document title,
under document type ‘Deprivation of Liberty Safeguards’ with the comments box used to indicate the nature
of the document. The Mental Health Act Office will then complete the DoLS form in RiO as below.
Link to DPT guidance on DoLS:
http://nww.devonpartnership.nhs.uk/default.asp?a=11359&m=0
Item
Date of
Assessment
Urgent
Authorisation
Date
Form 1 Urgent
Authorisation
complete
Duration (days)
Expiry Date
Reason for
Guidance
Enter the date that Deprivation of Liberty assessment was carried out..
Date Urgent Authorisation started
Tick for yes – form must be uploaded to the record as document type Deprivation of
Liberty Safeguards using the standard naming convention
Length of urgent authorisation
Date the authorisation expires
Refer to the uploaded documents including the document title and date where these
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Urgent
Authorisation
Extension Date
Form 1
Completed
Authorised
Duration (days)
Expiry Date
Reasons for
Extension
Standard
Authorisation
Start date
Form 4
Completed
Expiry Date
Reason for
Standard
Authorisation
Conditions of
Authorisation
Authorisation
Review
Date
Form 19
Completed
Reasons for
Review
Review Outcome
Suspension of
Authorisation
Date
Form 14
Completed
Reason for
Suspension
Suspension End
Date
Form 15
Completed
Reason for
Lifting
Suspension
refer to an urgent authorisation.
E.g. See uploaded document ‘UICStJC DoLS Urgent Form’ dated 12/09/11.
(UICStJC = Urgent/Inpatient Care, St John’s Court.- a list of team abbreviations is in
Section M, RiO Documentation)
Date extension starts
Tick if complete - form must be uploaded to the record as document type Deprivation
of Liberty Safeguards using the standard naming convention
Length of extension
Date the extension ends
Refer to the uploaded documents including the document title and date
Date this starts
Tick if complete - form must be uploaded to the record as document type Deprivation
of Liberty Safeguards using the standard naming convention
Date this ends
Refer to the uploaded documents including the document title and date where these
refer to a standard authorisation.
Refer to the uploaded documents including the document title and date
Date this was carried out
Tick if complete - form must be uploaded to the record as document type Deprivation
of Liberty Safeguards using the standard naming convention
Refer to the uploaded documents including the document title and date
Refer to the uploaded documents including the document title and date
Date this started
Tick if complete - form must be uploaded to the record as document type Deprivation
of Liberty Safeguards using the standard naming convention
Refer to the uploaded documents including the document title and date
Date the suspension came to an end
Tick if complete - form must be uploaded to the record as document type Deprivation
of Liberty Safeguards using the standard naming convention
Refer to the uploaded documents including the document title and date
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Recording in other areas of the record.
Care Plan
Risk Assessment
Progress Notes
Care plans should be created to identify ongoing care/ decisions that are taken for or
on behalf of someone who is assessed as not having capacity to take these decisions
themselves. The care plan should identify how the decisions in question are being
made, and how the person is being involved where possible. The Crisis, Relapse and
Contingency form should include the person’s preferences regarding future care and
this should be referenced in the Advance Directive form.
Where lack of capacity puts an individual at risk because of their inability to identify
and respond to risk, this must be included in the risk assessment.
Any intervention requiring an informal assessment of capacity or a decision to be
made on the individual’s behalf that does not fall within the criteria for a full
assessment should be recorded in the progress notes. Progress notes regarding a
risk incident should be linked to risk and the risk assessment updated. Progress notes
that refer to an advance directive/ decision particularly if this is a verbal statement
should be linked to significant events and the person’s preferences recorded in the
Advance Decisions form and/ or Crisis, Relapse and Contingency form as
appropriate.
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