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 to Liaison 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
2. 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 hours completed 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 and hospital 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 any wards dependent on needs.
Administrative Category: leave blank
Referral Comment: completed in hours by Team secretaries/liaison clinicians out 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 referral made. 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
3. DOCUMENTS FOR LIAISON
a) PROGRESS NOTE All progress notes need to start with:
“Liaison Psychiatry and the time the patient 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 incidents check 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 Children EVEN IF NO ACCESS TO CHILDREN and/or Adult Client form
located under risk information
Updated November 2012 KS 2
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e) Social Inclusion
f) Information Sharing and Consent located 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 Summary located 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 mental health 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 working save 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.
4. DIARY (all contact including phone calls etc to be entered and appointments must be outcomed within 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 face contact 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
is not the entry time to the record
Outcomes choose 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 options depending 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
5. DISCHARGE to 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 selfdischarged
Updated November 2012 KS 2
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