RiO Standard Operating Procedures
Standard
Operating
Procedures
(SOPs)
Standard Operating Procedures V5
14.10.2011
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RiO Standard Operating Procedures
MASTER INDEX
A. GENERAL INFORMATION ......................................................................................................................................................... 5
1. INTRODUCTION ................................................................................................................................................................................ 5
1.1 Searching this document................................................................................................................................................... 5
2. GUIDANCE ON THE USE OF RIO ........................................................................................................................................................... 5
3. LINKED REFERENCES.......................................................................................................................................................................... 5
3.1 Related Policies ..................................................................................................................................................................... 5
3.2 Confidentiality ...................................................................................................................................................................... 6
3.3 Secure Envelopes .................................................................................................................................................................. 6
3.4 Appropriate Access ............................................................................................................................................................... 6
3.5 Process Maps ........................................................................................................................................................................ 6
3.6 Help Files .............................................................................................................................................................................. 6
4. RECORDING ON OTHER INFORMATION SYSTEMS ..................................................................................................................................... 7
4.1 EPEX ...................................................................................................................................................................................... 7
4.2 Care First 6 & PARIS Social Care Systems ............................................................................................................................. 7
5. LOGGING ON AND OFF RIO ................................................................................................................................................................. 7
5.1 Logging on to RiO ................................................................................................................................................................. 7
5.2 Logging off from RiO ............................................................................................................................................................ 7
5.3 Unlocking Smartcards ........................................................................................................................................................... 7
5.4 What should I do if I have lost my card or it has been stolen? ............................................................................................. 7
5.5 What should I do if I have found a card? .............................................................................................................................. 7
5.6 Notifications ......................................................................................................................................................................... 8
6. SYSTEM ADMINISTRATOR TASKS .......................................................................................................................................................... 8
7. ACCESS TO RIO FOR STUDENTS, BANK STAFF AND STAFF EMPLOYED ON A NON-REGULAR BASIS ..................................................................... 8
7.1 NHSP ..................................................................................................................................................................................... 8
7.2 Medical Locums .................................................................................................................................................................... 8
7.3 Agency nursing staff ............................................................................................................................................................. 8
7.4 Bank Administrators ............................................................................................................................................................. 8
7.5 Workarounds ........................................................................................................................................................................ 9
7.6 Students ................................................................................................................................................................................ 9
8. WHO TO CONTACT ABOUT OPERATIONAL PROBLEMS .............................................................................................................................. 9
9. WHO TO CONTACT ABOUT RIO / PC / NETWORK PROBLEMS ................................................................................................................... 9
10. WHAT TO DO WHEN RIO IS NOT AVAILABLE ......................................................................................................................................... 9
10.1 Planned Downtime ............................................................................................................................................................. 9
10.2 Unplanned Downtime ......................................................................................................................................................... 9
11. CHANGES TO CLINICS AND ACCESS RIGHTS.......................................................................................................................................... 10
12. CHANGES TO THE SOPS / RIO ITSELF................................................................................................................................................ 10
13. STAFF CHANGES / MOVEMENTS ...................................................................................................................................................... 10
A.1 DEFINITION OF TERMS / ABBREVIATIONS ........................................................................................................................... 11
B. CLIENT SEARCH, DEMOGRAPHICS AND THE CASE RECORD .................................................................................................... 13
1. SEARCHING FOR A CLIENT FOR REFERRAL MANAGEMENT - PERSONAL/DEMOGRAPHIC DETAILS ...................................................................... 13
1.1 Client Search ....................................................................................................................................................................... 13
1.2 Searching previous electronic systems ............................................................................................................................... 13
1.3 Searching for Existing Paper Clinical Records ..................................................................................................................... 13
1.4. Duplicate Records .............................................................................................................................................................. 13
1.5 RiO record with no location details (S Flagged Clients) ...................................................................................................... 13
2 UPDATING CLIENT DEMOGRAPHICS..................................................................................................................................................... 14
3 CLIENT DETAILS............................................................................................................................................................................... 15
3.1 Client Names....................................................................................................................................................................... 16
3.2 Client Personal Contacts ..................................................................................................................................................... 17
4. CLIENT DEMOGRAPHICS - ADDITIONAL PERSONAL INFORMATION ............................................................................................................. 17
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5 CASE RECORD ................................................................................................................................................................................. 18
5.1 Alerts .................................................................................................................................................................................. 18
5.2 Checking Alerts ................................................................................................................................................................... 18
5.3 Significant Events ............................................................................................................................................................... 18
B1. POPULATING THE FRONT OF THE CASE RECORD .................................................................................................................. 20
C. CARERS RECORDS .................................................................................................................................................................. 21
1. CARER ASSESSMENT........................................................................................................................................................................ 22
2. CARERS CARE PLAN ........................................................................................................................................................................ 22
D. INPATIENT MANAGEMENT .................................................................................................................................................... 23
1. INPATIENT MANAGEMENT ............................................................................................................................................................... 23
1.1 Inpatient Admission ............................................................................................................................................................ 23
1.2 Inpatient Episode ................................................................................................................................................................ 24
1.3 Discharging an Inpatient .................................................................................................................................................... 26
1.4 Delayed discharge .............................................................................................................................................................. 26
1.5 Death of Inpatient .............................................................................................................................................................. 27
1.6 Ward Attenders .................................................................................................................................................................. 27
2. MEDICINES RECORDING ................................................................................................................................................................... 27
D1 SECTION 17 LEAVE ................................................................................................................................................................ 29
GUIDANCE FOR RC GIVING FORMAL SECTION 17 LEAVE PERMISSIONS ON RIO................................................................................................ 29
GUIDANCE FOR WARD STAFF ON CHECKING SECTION 17 LEAVE PERMISSIONS ON RIO....................................................................................... 29
GUIDANCE ON PRINTING A COPY OF SECTION 17 LEAVE PERMISSIONS FROM RIO WHEN REQUIRED ..................................................................... 29
OUT OF HOURS ................................................................................................................................................................................. 30
E. REFERRAL MANAGEMENT: TRIAGE, ALLOCATION, TRANSFER AND DISCHARGE .................................................................... 31
1. RECORDING REFERRALS ................................................................................................................................................................... 31
1.1 Managing Referrals between DPT Teams .......................................................................................................................... 31
1.2 Completing the New Referral Form .................................................................................................................................... 31
2. TRIAGE ......................................................................................................................................................................................... 32
3. ALLOCATION TO HCP ...................................................................................................................................................................... 33
3.1 Sharing a Caseload/Cases................................................................................................................................................... 33
4. DISCHARGING FROM RECOVERY/CARE COORDINATOR/ HCP CASELOAD ................................................................................................... 33
4.1 Discharging from Section 117 ............................................................................................................................................. 34
5. DEATH OF A COMMUNITY CLIENT ...................................................................................................................................................... 34
E1 – TEAM TRANSFER OPTIONS (SEE NOTES BELOW) ................................................................................................................ 35
E2 INTERNAL REFERRAL/ TRANSFER NOTES ............................................................................................................................... 36
F ASSESSMENT: INITIAL/ONGOING ASSESSMENT INCLUDING RISK. .......................................................................................... 37
1. INFORMATION SHARING & CONSENT ................................................................................................................................................. 37
2. CORE ASSESSMENT ......................................................................................................................................................................... 38
3. RISK ASSESSMENT .......................................................................................................................................................................... 40
4. SPECIALIST ASSESSMENT .................................................................................................................................................................. 41
5. SOCIAL INCLUSION – ACCOMMODATION AND EMPLOYMENT STATUS........................................................................................................ 42
F1 CAPACITY ASSESSMENT ........................................................................................................................................................ 43
1. GENERAL GUIDANCE AND REFERENCES ............................................................................................................................................... 43
2. MCA FORM COMPLETION GUIDANCE ................................................................................................................................................ 44
Advance Decisions and Statements form ................................................................................................................................. 44
Best Interest Considerations ..................................................................................................................................................... 44
Capacity Assessment ................................................................................................................................................................ 45
Capacity Contacts ..................................................................................................................................................................... 45
Deprivation of Liberty ............................................................................................................................................................... 45
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RiO Standard Operating Procedures
Recording in other areas of the record. .................................................................................................................................... 47
G. SAFEGUARDING .................................................................................................................................................................... 48
1 SAFEGUARDING CHILDREN ................................................................................................................................................................ 48
2 SAFEGUARDING ADULTS ................................................................................................................................................................... 49
H. APPOINTMENT MANAGEMENT (RECORDING CONTACTS) ..................................................................................................... 52
1. HCP DIARY / CLINICS ...................................................................................................................................................................... 52
1.1 OTHER ACTIVITY........................................................................................................................................................................... 53
1.2 APPOINTMENT TYPES .................................................................................................................................................................... 54
1.3 RECORDING AN OUTCOME FROM CONTACTS/APPOINTMENTS .............................................................................................................. 54
1.4. CLIENT APPOINTMENTS & CONTACTS .............................................................................................................................................. 55
1.5 RECORDING DNA ......................................................................................................................................................................... 55
H1 - USE OF CONSULTATION CLINIC TO RECORD CONTACT BY DUTY DOCTORS/ CONSULTANTS ON CALL. ................................ 56
I. PROGRESS NOTES ................................................................................................................................................................... 57
1. PROGRESS NOTE ENTRIES ................................................................................................................................................................. 57
2. STANDARDS OF RECORD KEEPING ....................................................................................................................................................... 59
3. ENTRIES BY ADMINISTRATORS/ SECRETARIES ON BEHALF OF CLINICIANS ..................................................................................................... 59
4. EMAILS......................................................................................................................................................................................... 60
J. CARE PLANNING/ RECOVERY PLANNING & CPA /REVIEW ...................................................................................................... 61
1. RECOVERY COORDINATION. .............................................................................................................................................................. 61
1.1 Signing of Care Plans .......................................................................................................................................................... 64
1.2 Care Plan Library ................................................................................................................................................................ 64
1.3 Section 117 Aftercare recording ......................................................................................................................................... 64
1.4 Recording Key Safe Details within RiO ................................................................................................................................ 64
2. MDT REVIEW MEETINGS & SUPERVISION........................................................................................................................................... 64
3. MAPPA ....................................................................................................................................................................................... 65
3.1 MAPPA Review Form .......................................................................................................................................................... 65
K. DIAGNOSIS, CLUSTERING & OUTCOME MEASURES ............................................................................................................... 67
1. DIAGNOSIS .................................................................................................................................................................................... 67
2. CLUSTERING ASSESSMENT & ALLOCATION........................................................................................................................................... 67
3. OUTCOME MEASURES ..................................................................................................................................................................... 68
L. MENTAL HEALTH ACT ADMINISTRATION ............................................................................................................................... 69
1. APPROVED MENTAL HEALTH PRACTITIONERS (AMHPS) ........................................................................................................................ 69
Completing the MH1 Form: ...................................................................................................................................................... 69
2. RECORDING MENTAL HEALTH ACT INFORMATION ON RIO ..................................................................................................................... 69
3. ACCESS TO RIO FOR EXTERNAL PARTIES RELATING TO PEOPLE WHO USE OUR SERVICES AND WHO ARE SUBJECT TO THE MENTAL HEALTH ACT ......... 69
M. RIO DOCUMENTATION ......................................................................................................................................................... 71
1. EDITABLE LETTERS .......................................................................................................................................................................... 72
2. TEAM ABBREVIATIONS FOR USE IN DOCUMENT TITLES ............................................................................................................................ 73
3. UPLOADING DOCUMENTS................................................................................................................................................................. 75
4. DOCUMENT TEMPLATES VIA INTRANET/ SHARED DRIVES........................................................................................................................ 75
5. SCANNING POLICY........................................................................................................................................................................... 75
6. SHREDDING POLICY ......................................................................................................................................................................... 75
7. DOCUMENT NAMING CONVENTIONS.................................................................................................................................................. 75
8. PRINTING CLINICAL INFORMATION FROM RIO ...................................................................................................................................... 76
Standard Operating Procedures V5
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RiO Standard Operating Procedures
A. General Information
1. Introduction
RiO is the primary care record for people who use the services of Devon Partnership Trust (DPT). It will
replace the majority of paper records with the exception of specific paperwork that is required to provide a
safe service if RiO is not available, e.g. medication charts and EEG results and copies of key documents
such as Mental Health Act paperwork. Mental Health Act Administrators will keep and maintain a separate
record – specifically for the documentation required for the Mental Health Act.
This document provides a framework and guidance for DPT staff (including all bank and temporary staff). It
provides essential information relating to the patient journey and supporting processes and policies.
This is a working document and any amendments to policy or procedures will firstly be submitted for
ratification to the RiO Clinical Governance Committee and be approved through a formal change process
before the amendments will be incorporated into this document. Further details of the RiO Clinical
Governance Committee can be found on the RiO pages of the Intranet or via the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
Specific guidance regarding Best Practice and Consistency of Recording in RiO is available on the Intranet
on a team/ function basis e.g. for MWA, RIL, Liaison, Inpatients etc. See link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
1.1 Searching this document
If you are unable to find the guidance you are looking for in the table of contents, you can use Ctrl+F (press
F while holding the Ctrl key) to access the find function in Word. This allows you to enter a key word /
phrase and click Find Next. You will then be taken to the first instance of that word / phrase in the
document. If the section you are taken to does not contain the guidance you are looking for, click Find Next
to go to the next example.
2. Guidance on the Use of RiO
There are 3 types of documents which will guide use of RiO. These are the Standard Operating Procedure
which details how DPT is using RiO, the Best Practice & Consistency of Recording guidance which details
what should be recorded where and when for particular teams and the How to Guides which give click by
click instructions on specific items. This guidance is now organised by team function on the RiO pages of
the Intranet.
3. Linked References
This document contains a number of links to other material and it should be read in conjunction with this.
Some examples are below.
3.1 Related Policies
All DPT policies and procedures can be found at:
http://nww.devonpartnership.nhs.uk/default.asp?a=130&m=0
Related polices and/or procedures are referenced throughout this document as required.
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3.2 Confidentiality
The duty of confidentiality remains unchanged from the position with regards to paper notes See policy
GV03 http://nww.devonpartnership.nhs.uk/default.asp?a=8428&m=0
Specific guidance regarding confidentiality in relation to RiO is available on the Intranet via
the RiO pages under ‘Guidance on Recording Information in RiO’ and this includes dealing
with concerns raised by people who use our services.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
3.3 Secure Envelopes
Devon Partnership Trust has agreed that due to the nature of psychoanalytic psychotherapy, it is
appropriate that a higher level of confidentiality is given to their process notes via a ‘secure envelope’. It is
of the utmost importance that psychotherapists share clinically relevant information, in particular risk
information, in the progress notes in RiO and in discussion with appropriate, involved parties. The progress
notes should include reference to the fact that detailed notes have been recorded within a Secure Envelope.
Use of the secure envelope is managed via Information Governance using a secure shared drive and a
process of password protection (contact Information Governance for further details). Use of this process
under other circumstances will need to be approved through Information Governance. (See Secure
Envelope guide on the RiO part of the Intranet under Psychology Guidance).
3.4 Appropriate Access
RiO will challenge users when accessing records that are not open to them through a ward or their team.
This process audits access and is reported to the Trust to ensure appropriate access to the record can be
monitored. A reason for access must be selected and a comment detailing this MUST be entered in the text
box. If access is challenged, the comment will enable you to explain why you accessed the record.
Staff are reminded that they have a duty only to access information required by them in order to pursue their
duties.
Staff will only get access to RiO once they have completed the required training. To request training, see
the RiO pages of the Intranet.
3.5 Process Maps
Each Service has its own process map which should be referred to in order to provide local service
guidance. The process maps and the generalised flow charts can be found on each team/function guidance
section on the RiO pages of the intranet and the RiO Blog
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
3.6 Help Files
Each RiO page has a help icon you can click to see help relating to the page currently open. Many of these
files are not yet populated but the number that are is increasing. Currently there are help files available on
the Mental Capacity form screens, the Care Planning screen, the CPA management screen, the CPA
scheduling screen, the Alerts screen, the Client demographics screen, the Core Assessment screen, the
front of the case record screen, the case record search screen and the clustering assessment and
allocation screens. These files contain relevant information from the SOPs and may also contain links to
relevant websites or documents such as the clustering booklet. Sections of the SOPs that can also be
viewed in the help files will have the icon above next to them.
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4. Recording on Other Information Systems
4.1 EPEX
The information on ePEX will continue to be available for staff to access historical information.
4.2 Care First 6 & PARIS Social Care Systems
Staff who access Care First 6 or who currently use the system will need to use it according to local
Directorate and Team arrangements. These may vary depending on area and determined by service
managers.
The HCP is responsible for ensuring that information which needs to be recorded on other information
systems continues as per local operating procedures.
5. Logging on and off RiO
Access to RiO is controlled with smartcards. Staff are responsible for ensuring that they have their
smartcards with them when required and that they are not shared with anyone else.
If there is any concern that a passcode has been compromised, it must be changed immediately.
5.1 Logging on to RiO
All staff needing access to RiO will be issued with a smartcard. The smartcard, along with a passcode, is
used to log into RiO. For smartcard issues, please contact the Application Support Team in the first
instance. (01392 675679) or DPT.servicedesk@nhs.net
5.2 Logging off from RiO
To log off from RiO, click the ‘log off’ hyperlink and remove the smartcard. In an emergency it is acceptable
to remove the smartcard without logging off from RiO. This will close any open RiO pages but unsaved
entries will be lost. The computer should still be locked (CTRL+ALT+DEL) as per Trust policy.
5.3 Unlocking Smartcards
A smartcard will be locked if the incorrect passcode is entered three times. All teams should have at least
one member of staff who is able to unlock smartcards. This may be a RiO Champion or someone else who
has had the relevant training and the relevant access added to their smartcard profile. If there are other
problems with your smartcard, please contact the Applications Support Team. (01392 675679) or
DPT.servicedesk@nhs.net
5.4 What should I do if I have lost my card or it has been stolen?
Any loss of the Smartcard should be reported to Applications Support Team (01392 675679) or
DPT.servicedesk@nhs.net as soon as possible. You will also need to complete a Datix incident form.
A new card will be issued.
5.5 What should I do if I have found a card?
Please return it to: Applications Support Team (01392 675679) or DPT.servicedesk@nhs.net.
For further information about smartcards, please see the Smartcard section of the RiO pages of the intranet
or via the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11069&m=0
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5.6 Notifications
This symbol indicates that there are unread notifications waiting. These are automated messages
generated when certain actions are performed in RiO. You can add manual notifications as a to do list but
this function MUST NOT be used for communication instead of email as there is no trail and if a notification
is forwarded, you will no longer have access to it or be able to show that it was sent. For further guidance
see the RiO pages of the Intranet or contact the Application Support Team. (01392 675679) or
DPT.servicedesk@nhs.net
6. System Administrator Tasks
System Administrators will be responsible for the following:
-
Registration of a new Client on the SPINE
Registration of a Death
Gender Dysphoria (history deletes)
Issues relating to synchronisation
If you require any of the above, please contact Applications Support Team (01392 675679) or
DPT.servicedesk@nhs.net
7. Access to RiO for Students, Bank Staff and Staff Employed on a Non-regular
Basis
This pertains to students on placements, NHS Professional Staff, Agency nursing staff, Medical Locums
and Bank Administration staff.
7.1 NHSP
Staff on NHSP will not be offered shifts unless they have completed their Rio training. Their smartcard will
become inactive after four months if the individual has not taken up a shift with DPT.
NOTE: due to the way they are set up on the system, NHSP staff will NOT be able to do the following:
Admit a person to a ward; Transfer out to a different Ward, Bay or Bed; Change the Named Nurse or
Consultant; Perform a bed swap; Record a person on Sleep Over; Record AWOL; Record Leave.
They WILL be able to: update Admission Record via the admission option, including recording delayed
discharge; Discharge a person.
7.2 Medical Locums
Medical staffing will arrange training for locums as soon as possible as part of the recruitment process.
7.3 Agency nursing staff
-
Agencies used by the Trust will be contacted with the details of RiO
Training will be offered to staff without payment
RA sponsorship and production of the smartcard is conducted as part of the training
The smartcard will lapse in 4 months if the staff member has not worked.
7.4 Bank Administrators
As for Agency Nursing Staff above.
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7.5 Workarounds
Locums and bank staff may be required at very short notice without adequate preparation. If the above is
not possible then the following workaround will be instituted.
-
-
To provide access to RiO for the bank/locum staff, the DPT staff member in charge of the shift will
arrange for accompanied viewing access from a DPT staff member.
Locum / Bank paper notes to be written by the Bank member, signed and dated. This original copy
should be scanned into RiO and the contents transcribed into a progress note by a DPT member of
staff, adding the name & profession of the bank worker. As such the original is preserved and the
progress notes include all clinical records.
Non-RiO Bank staff in a ward environment should only work as second qualified i.e. there should be
another qualified member of staff on shift as well.
7.6 Students
It is essential that the RiO training department and Applications Support Team are notified when students
are expected in order to set up training, smartcard and access rights to the system. Their supervisor will
also need to be given access rights to validate their notes. It is also essential that the Applications Support
Team is notified of the end of the placement so that they can withdraw student access rights. This applies
even if the person in question also works for DPT in another role as they will have separate access rights
for each role.
8. Who to Contact about Operational Problems
In the first instance, if you have any operational queries, please speak to your Clinical Team Leader.
If the Clinical Team Leader is unable to resolve your query, they will escalate this to the Managing Partner
or Head of Profession.
9. Who to Contact about RiO / PC / Network Problems
In the first instance, any problems should be reported to the local IT Service Desk to clarify local hardware
and network issues are not preventing RiO access.
RiO support is available from:
Applications Support Team (01392 675679) or DPT.servicedesk@nhs.net.
10. What to do when RiO is not available
Lack of availability should be reported through local service desks or the Applications Support Team.
10.1 Planned Downtime
There will be times when RiO is unavailable for short periods of time to enable upgrades and maintenance
on the system. During periods of planned downtime, the RiO contingency process should be followed. The
process can be found on the intranet or RiO Blog and includes blank templates of relevant RiO forms.
http://nww.devonpartnership.nhs.uk/default.asp?a=11345&m=0
10.2 Unplanned Downtime
In the event of RiO not being available, inform the Application Support Team in the first instance and then
the RiO contingency process should be followed. The process can be found on the intranet or RiO Blog.
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11. Changes to clinics and access rights
If you require any changes to be made to RiO such as changes to clinics and access rights etc., the Change
Request Form (on the Application Support Team section of the RiO pages on the intranet) must be
completed, authorised by your Clinical Team Leader and submitted to the Applications Support Team
DPT.servicedesk@nhs.net.
12. Changes to the SOPs / RiO itself
Changes to the way in which RiO is used within DPT are considered and agreed/ denied by the RiO Clinical
Governance Committee (RCGC) which meets monthly. Issues raised at Local Delivery Unit (LDU) level
should be forwarded to the RCGC for consideration and response. The RCGC reports to the Trust
Management Board. Terms of Reference and other information can be found on the RiO pages of the
Intranet.
When updates to RiO are to be implemented, the RCGC will develop and publish guidance regarding any
clinical/ organisational risk following from the change.
The RCGC will review change requests from other Trusts using RiO and comment back on whether these
would be supported by DPT or not. Where it is considered appropriate to circulate these for a wider opinion
– specialist use for example – the RCGC will do so.
The RCGC will coordinate and authorise change requests from DPT regarding alterations to the system
itself. Suggestions should be directed to the RCGC using the RiO email address below and putting RCGC
in the subject box.
dpn-tr.rio@nhs.net
13. Staff Changes / Movements
All staff changes, movements, change of base or role etc should be notified via the Trust change of
circumstances form – see link below.
http://nww.devonpartnership.nhs.uk/default.asp?a=11391&m=0
This information will then be passed to the Application Support Team to make changes to RiO.
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A.1 Definition of Terms / Abbreviations
Those marked with * are approved abbreviations and may be used in clinical records without additional
explanation. Other abbreviations may only be used if there is an initial explanation of their meaning within
the text box in which they are used. This must be repeated in future uses e.g. use of a non-approved
abbreviation in progress notes should include an explanation in each progress note in which they are used.
E.g. ‘VC (Vocational Coach) Joe Bloggs accompanied Miss X to the volunteer centre.’
Term
Definition
Alias
Also known as
AMHPs *
Approved Mental Health Professional replaced Approved Social Worker
(ASW)
AWOL*
Absent without leave
CAMHS*
Care Plan
Child and Adult Mental Health Service
The written framework that provides direction for the delivery of care used
by RiO. This equates to recovery planning in DPT
Carer
Client
A carer is anyone who provides significant care on a regular basis for a
member of their family or a friend – but is not employed to do so
A RiO term for people who use our services
Contacts
Measurement of work-related activity
CPA *
Care Programme Approach
DAS*
Depression and Anxiety Service
Discharge
Discharge from DPT
DPT *
Devon Partnership Trust
ED*
Eating Disorders
Editable letters
EI (STEP)*
A set of letter templates available within RiO
Early Intervention (Specialist Team in Early Psychosis)
ENDAS*
Exeter and North Drug and Alcohol Service
e-Pex
GP*
DPT Electronic Record System (available in read-only mode)
General Practitioner
HCP *
A RiO term, Healthcare Professional (HCP) is any clinical professional
identified on RiO as part of a team. They may be Care Coordinators (for
CPA) or Recovery Coordinators
Health of the Nation Outcome Scales - HoNOS is the most widely used
routine clinical outcome measure for Mental Health
Information Governance
HoNOS *
IG
Inpatient
Discharge
Either transfer to another part of the Service or discharge from DPT.
LD*
Learning Disability
Lead HCP
MAPPA*
MDT*
A RiO term, the Lead HCP (healthcare professional) for a team. This is
often the team manager or community team leader (CTL)
Multi-Agency Public Protection Arrangements
Multi Disciplinary Team
MRSA *
Methicillin-Resistant Staphylococcus Aureus
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MWA*
Mental Wellbeing and Access
Named Nurse
Lead nurse or mental health practitioner in an inpatient setting
Nearest Relative
In the Mental Health Act the nearest relative is a clearly-defined person
appointed from the criteria listed below and has a legally-defined role in the
Act:
OPMH*
1. Husband or Wife
2. Son or Daughter
3. Father or Mother
4. Brother or Sister
5. Grandparent
6. Grandchild
7. Uncle or Aunt
8. Nephew or Niece
9. Civil Partner
Despite the widespread use of the phrase, ‘next of kin’ is not defined by the
law and can be whoever the person chooses.
Older Peoples Mental Health
PARIS
Electronic Information System used by Torbay Care Trust.
Recovery Planning
Levels
RIL*
There are four levels:
1 Care Coordination (Please use enhanced CPA in RiO)
2. Recovery Coordination by named practitioner
3. Active Review
4. Responsive Review
Recovery and Independent Living
RiO
Is the system that DPT will be using as the primary electronic care record
S Flagging
Process by which a person can request that their demographic details be
flagged nationally as ‘sensitive’ and are therefore not drawn down to local
systems such as RiO. Contact details can be stored locally within the record
but are not synchronised with the spine. This process is carried out via GPs
and the National Back Office.
When a person receives care from one ward, but occupies a bed in another
ward
Next of Kin
Sleepover
SOP
Standard Operating Procedures
Spine
National Database of summary patient records synchronises demographic
information with RiO
UIC*
Urgent and Inpatient Care
Validation
Electronically validating an entry in the electronic record. The equivalent of
signing an entry in the paper notes.
Ward Attender
Someone who attends a ward without being admitted to that ward.
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B. Client Search, Demographics and the Case Record
1. Searching for a client for referral management - Personal/Demographic
Details
1.1 Client Search
To search for a person in RiO click on the Client Record icon and always select the Case Record option
NEVER Registration – the search screens are identical but registration potentially creates duplicate records
within RiO and on the Spine.
Peoples are searched for using a minimum of 2 of the following: family name, given name, first line of
address, postcode, gender and date of birth or using either the NHS number or the ePex number (no other
details are required when searching using these numbers). If you are uncertain about the spelling of a
name you can use the ‘wildcard’ function e.g. Peter* will find Peters, Peterson and Petersen. The system is
set to use soundex i.e. to look for similar names etc and to search aliases as a default.
In situations such as crises and MHA assessments, it may be that this information is not immediately
available or that the person gives false information. Staff should follow existing clinical practice in working
with individuals under these circumstances and establish their identity as soon as possible. Temporary
paper notes can be kept until the RiO record can be accessed when all information must be entered and the
paper notes uploaded and shredded.
If you have the required details but are unable to find the person on RiO, a search of the national system
(the Spine) will need to be carried out in order to create a new RiO record. To do this you will need the
person’s family name, date of birth and gender. Their postcode can also be added to reduce the number of
potential results. If you cannot find the person on the National System please contact the Application
Support Team (01392 675679) or DPT.servicedesk@nhs.net
1.2 Searching previous electronic systems
If a national search is required, there will be no clinical information in the RiO record. Therefore, it is
important to check on ePex to see if care has been provided in the past within the Trust. Previous
assessment/ risk information should be reviewed and incorporated into the RiO record as appropriate. If
assessment information is copied into RiO forms, the source, author and date should be indicated e.g. From
Discharge Summary by Dr Jones date 12/10/10.
1.3 Searching for Existing Paper Clinical Records
In the first instance the existing paper records will remain unchanged. Staff access to paper records will not
change and depends upon local approaches. Paper records should not be added to.
1.4. Duplicate Records
If a duplicate record is discovered send the details in an email to the Applications Support Team
immediately, using the email address below:DPT.servicedesk@nhs.net
1.5 RiO record with no location details (S Flagged Clients)
Some people whose demographic details are considered particularly sensitive, usually for safety & security
reasons, may have their national record ‘S Flagged’ via their GP. When a record has been S Flagged no
location identifiable information (Address, GP etc.) will appear on the RiO case record. If you come across
such a record, please contact the Application Support team as above.
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2 Updating Client Demographics
Once the person is found, synchronisation with the spine may occur. The most up to date details will need
to be entered and synchronised. See the Synchronisation guide on the Training Material section of the RiO
pages of the intranet.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
There is a Basic Information Form among the Best Practice and Consistency documents which may be
used to check / gather this information at initial assessment or at review points if appropriate.
A printable version of the demographic screen can be found in Client Demographics, View Demographics
on the right hand side of the case record.
At other stages in the care pathway (e.g. review of Care Plan or where RiO indicates there is a difference
between the information recorded on the spine and the information given by the person), demographic
information will need to be updated. When updating demographic information, it is important to close the
existing record (telephone number, personal contacts etc.) by adding an end date and then creating a new
record. You should not change the current information as this will prevent a viewable history being retained.
Recording Key Safe Details within RiO
This information MUST NOT be recorded in the address field in RiO as this makes it accessible via the
national spine. Where it has been agreed that staff will access a person’s home using a key safe, this
should be recorded in a Care Plan. The reason for the use of the key safe should be indicated in the
problem /need box along with the names of staff authorised to use this and the key safe details in the
intervention. The person’s consent to this should be indicated in the text of the Care Plan and, where
possible, by the person signing their whole Care Plan including this aspect and this signed document being
scanned and uploaded to RiO.
Thought will need to be given to the distribution of the Care Plan when it contains this kind of information
and where possible the person should decide who should receive this. The printable Care Plan can be
edited before printing/ sending to other parties to remove this information if necessary for security reasons.
Guidance:
Data Mismatch
First Check
Action
Person’s primary
address is different
Ensure source of information
is reliable.
Person gives a
temporary address
in addition to their
primary address
Person wants
correspondence sent
to an address other
than their primary
address
Ensure source of information
is reliable
Put an end date for the existing address
and then record new primary address on
RiO and update the spine
Record this address in Full Name (Client
ID), 'addresses' and add as a temporary
address
Person gives a
different date of birth
Ensure source of information
is reliable
Ensure source of information
is reliable
Record new address in Full Name (Client
ID), 'addresses' and add as a
correspondence address on RiO. Add the
request for letters to be sent to the
correspondence address to the
Information Sharing & Consent form.
Confirm with documentation where
available and record new date of birth on
RiO and update the NCRS (NHS Care
Record System)
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Person advises
change of GP
Contact new GP to confirm
person is now registered with
them - advise GP that they
need to update their record
This can only be updated by the GP
practice on the national demographic
system.
3 Client Details
The RiO client details screen contains demographic information about people who use services and must
be kept up-to-date. It is accessed via the Full Name (Client ID) hyperlink on the front of the case record.
Many of these fields are required as part of the Mental Health Minimum Data set and data regarding the
completion or otherwise of this will be part of the reporting back to managers. The following table provides
guidance on the information that must be updated for all people who use services as it becomes available:
Item
Guidance
To be
completed
on RiO
Title
For example, Mr, Mrs, etc. This is required to pull through into
RiO letters
Yes
Marital
status/Civil
Partnership)
Gender
Select the appropriate option from the drop down list
Yes
If different, contact the Application Support Team
Yes
Date of Birth
There is a tick box below this field to indicate that the date of
birth is estimated
Yes
Nationality
Yes
Religion
Yes
Ethnicity
Yes
Address from
date
Select the most appropriate code from the full national list of
ethnicity codes as identified by the person themselves. If the
person’s ethnicity cannot be ascertained at registration select
‘Not Known (not requested)’ or ‘Not Known (unable to request)
and update within one week of the first assessment. If the
person does not want to specify their ethnicity or is unable to do
so, select ‘Not Stated (Client refused)’ or ‘Not Stated (Client
unable to choose)’.
If yes is selected this will show on the front page of the person’s
RiO record. You must also indicate the person’s first language
by selecting from the drop down list.
Must be recorded and updated if the patient moves. If the
current address is unknown, use the postcode ZZ99 and type
‘no fixed abode’ in the address field, this must be entered
manually
NB: Other addresses, e.g. a temporary address, a
correspondence address, etc should be recorded in the
‘addresses’ section of RiO
Key safe details MUST NOT be recorded in the address field.
If not known the date of referral should be recorded as this is the
earliest record we have of the address.
Telephone
number
In order for the main telephone number to appear on the
front of the case record, the ‘context’ selected must be
Yes
Interpreter
required
Client’s current
address –
Yes
Yes
Yes
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‘Office Address’. If the number changes it is important to enter
an end date for the existing number and add a new number
rather than edit the existing one in order to retain a history in the
system.
This will already be recorded in RiO
Date registered
with GP
GP details
This will already be recorded in RiO – please note that at
present the practice details will be accurate but the name of
the GP may not be the GP who referred or whom the person
knows. This is because the NCRS/Spine records people as
patients of the practice not the GP. You can record the
referring or preferred GP’s name in Client Personal
Contacts if necessary using Type: Other, Relationship: Not
Related and recording ‘GP’ in the comments box. It is not
possible to change the GP name on the front page of the
record locally. The referring GP can be recorded in the
referral entry screen.
They must have a RiO Case Record to be linked to the Person
who is using our services
Main Carer
Other Carer
Yes
Yes
Yes
Yes
First mental
health contact
date
First Language
If known
Yes
Yes
3.1 Client Names
The following table provides guidance on the information that must be recorded for all people who use our
services, where appropriate, as soon as it is available:
Item
Guidance
Client name
changes –
Options:
 Alias
To be used when a client is “also known as” or is consistently
using another full name
 Preferred Name
When the first name they prefer people to use is different from
the first name on the record, e.g. Becky instead of Rebecca, Jim
instead of James.
 Birth Name
For example, returning to birth name following divorce
 Maiden Name
Prior to marriage
 Bachelor Name
Prior to marriage
 Other
If none of the above apply
 Client Merge
Do not use – Application Support Team only.
To be
completed
on RiO
Yes
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3.2 Client Personal Contacts
The following table provides guidance on the information that must be recorded for all people who use our
services, where appropriate, as soon as it is available:
Item
Guidance
To be
completed
on RiO
Next of kin(s)
See definition of terms. Select Next of Kin from the drop down
list for the ‘type’ of contact.
Select dependant as the ‘type’ of contact in order for this to
appear on the front of the case record. Use the comment box
to record the child’s date of birth / date of adoption and use
this date as the start date for the contact. Also include the
current school in the comment box (this will need to be
updated as appropriate).
Select Dependant as the contact type from the drop down list.
Yes
People who use
our services with
carers
Professional
contacts
See below - Carers Records
Yes
DO NOT USE – Not currently operational. Professional
contacts should be recorded as personal contacts with the
appropriate contact type selected
Yes
Personal
Contacts
For example, child and families teams, or housing
organisations, Carers who do not have a separate carer record
Yes
Dependant
children of the
person who uses
our service
Other
Dependants
Yes
Yes
Where a client has dependants, support for them in a crisis needs to be included in Crisis, Relapse and
Contingency planning.
Please Note: Personal Contacts cannot be added without an address. Where the address of the person
being recorded as a personal contact is not known, the postcode ZZ99 can be entered manually.
4. Client Demographics - Additional personal information
The following table provides guidance on the information that must be recorded for all people who use our
services, where appropriate, as soon as it is available. The second part of this form is included in the Basic
Information form to be used with people at initial assessment and then transcribed into the form in RiO.
Please note this is an ‘Add type’ form and once created is updated as information changes.
Item
Guidance
To be
completed
on RiO
Mobility
Describe mobility needs particularly where these might restrict
access to services. There is limited text for this. If specified, the
information will show on the front page of the person’s case record
Yes
Braille
If ticked, the information will show on the front page of the
person’s case record
Yes
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Signer
Disability
Sexual
Orientation
If ticked, the information will show on the front page of the
person’s case record. You can indicate British Sign Language as a
first language in the demographics section if required
The information required for this section of the form can be
gathered using the Basic Information form (available on the
intranet RiO pages) and should then be entered in this form. NB:
the person is entitled to refuse to provide this information if they so
wish.
The information required for this section of the form can be
gathered using the Basic Information form (available on the
intranet RiO pages) and should then be entered in this form. NB:
the person is entitled to refuse to provide this information if they so
wish.
Yes
Yes
Yes
5 Case Record
The front page of the patient record highlights risks, physical alerts, dependants – including those on Child
Protection Plans, carers, the need for an interpreter, and special requirements for physical disabilities. It
also provides all the required links to the patient’s clinical and other information.
5.1 Alerts
This is mainly used to record details of allergies. Other physical health information including infection history
should be recorded in the Physical Assessment/ History/ Examination forms in the Core Assessment. Care
Plans will be used to address relevant physical needs.
Information regarding allergies must also be recorded on all other relevant systems/records.
NOTE: Risk alerts are not recorded here – see the Latest Risk Information link on the front of the case
record.
5.2 Checking Alerts
If the Alerts icon on the person’s case record front screen is red, it is the responsibility of all staff to check
the content and take the necessary action(s).
5.3 Significant Events
This refers to a list in the Client Related Data View section of the case record. Some actions in RiO will
generate an automatic entry to this list i.e.:
Admission
Care Plan Opened
Discharge
Discharged Referral
Leave END
Leave Start
MHA Section
Nearest Relative Decision Recorded
Nearest Relative Displacement
Patient Reported AWOL
Patient Returned From AWOL
Referral
Risk Related Incident/Progress Note
Section Expiry Date Extended By AWOL
Significant Progress Note
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Sleepover
Transfer
Guidance on marking progress notes as referring to a significant event can be found in the SOPs section on
Progress Notes (Section I)
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B1. Populating the front of the Case Record
Completion of the relevant fields in the following forms populates the front of the case record:
Mental Health Legislation/ Protection of Vulnerable Adults (In Core Assessment). This form records if
someone is on an Adult Protection Register (Safeguarding List).
Latest Risk Information: This is the alert function for risk in RiO. It is therefore essential that risk
information is entered on the risk assessment form or where appropriate, in a progress note linked to risk.
This makes the information available to anyone clicking on the Latest Risk Information link on the front of
the case record.
Victim to be notified of Leave? This is populated by ticking the box related to this on the Risk Assessment
form. Ticking the box indicates yes, leaving the box blank will leave the front of the case record blank.
Access to Child who has a Protection Plan? This is populated by completion of the Safeguarding
Children, Adult Client, Form 2. This should only be completed if the person has regular contact with a child
who has a child protection plan.
Client has a Child Protection Plan? This is populated by the completion of the Safeguarding Children –
Child Client form.
Preferred Name: This is populated within the demographic screens accessed via the Full Name (Client ID)
link on the front of the case record. Click on client names and add a new name with ‘preferred name’ as the
name type.
Dependants. Populated by adding a personal contact via the demographic screen with ‘Dependant’
selected as the type of contact.
Does the person have a carer?: The answer that appears here is drawn from the drop down box offering a
choice of Yes/No/Not Assessed in the Client & Carer’s Understanding of Assessment form.
Mobility Issues: The Additional Personal Information form (In Client Demographics) records mobility issues
and it is possible to enter ‘none identified’ in the relevant text box. It also identifies whether an interpreter is
required.
The person’s role can be altered by going into the demographic screen via the Full Name (Client ID) hyper
link on the front of the case record.
It is not possible to enter ‘none’ against dependants – it would be worth indicating that this had been
assessed either within the assessment forms (Mental Health Legislation/ Protection of Vulnerable Adults or
Social History/Care Management in Core Assessment) but this would not be apparent on the front of the
case record.
Contact Number. When entering a main contact number (whether mobile or land line) in the
communications section of the Client demographics screen, choose ‘Office Address’ as the context to
ensure this number is displayed on the front of the Case Record.
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C. Carers Records
An individual may be recorded on RiO just as a carer if they are responsible for a person’s care but are not
actually seen as a person using our services themselves. If they are both client and carer, their record must
be amended to show that they have both roles. Carers are those who have taken responsibility for looking
after the needs of another individual, as defined by the Carer Recognition and Services Act 1995. The Trust
has a specific target regarding the offering of a carer’s assessment to those caring for someone with
dementia which has financial implications for the Trust if not met. Guidance on recording in RiO to
demonstrate that CQUIN targets have been met is available on the Best Practice & Consistency page of the
RiO part of the Intranet.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
An unpaid carer is entitled to a Carers Assessment. The assessment is about their needs in relation to their
caring role rather than about the person they are caring for and this should be offered to all carers. There
are Carer Support Workers in the Trust who can offer individual support/ advice. The link below also
provides advice about developing carer’s Care Plans.
http://www.direct.gov.uk/en/CaringForSomeone/index.htm





A carer must have a case record on RiO before appointments can be booked for them.
A carer must have a case record on RiO before details can be recorded of whether the Carer’s
assessment has been offered. This information must be recorded for ALL carers who have a case
record in RiO
A maximum of two carers can be linked to any one client in RiO.
The first step is to search for the Carer using the same process as searching for a person using our
services. If no local record exists, you will need to search nationally using the person’s full name and
date of birth. If you are still unable to find the person contact the Application Support Team for
assistance.
Once found, ensure that the “Person’s Role” is set to either Carer or Client & Carer on the client details
screen.
NOTE: Carers are recorded in RiO if they are caring for someone who uses DPT services. People using our
services who are carers for people who are NOT using DPT services (children, dependant parents/ siblings/
partners etc) should not have their role updated in this way. The dependants should be recorded through
personal contacts.
The next step is to link the Carer to a Client. This is done by accessing the person using our service’s Case
Record and editing the Client Details by clicking the Full Name (Client ID) hyperlink.
Item
Guidance
Main Carer
Search for Carer using the magnifying glass next to this field
which will take you to the search screen. When you find the
correct name, select it and it will be pulled through to the Person
using our service’s demographics.
To be
completed
on RiO
Yes
This will update the Carer’s role information and display the person using our service they are caring for.
However, the carer’s name will not appear on the front of the person using our service’s case record and
their contact details will need to be added in the personal contacts screen choosing ‘informal carer’ as the
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contact type. You will need to enter their postcode to search for the address. Telephone and email contacts
can be added here.
This then enables appointments to be booked for a Carer. Carer’s do not need a referral in RiO.
1. Carer Assessment
This is found in the ‘Role as a Carer Information’ section on the front of the Carer’s case record.
Item
Guidance
To be
completed
on RiO
Carer Assessment
Complete all appropriate items for carers who are receiving a
carer’s assessment.
Yes
2. Carers Care Plan
This is found in the ‘Role as a Carer Information’ section on the front of the carer’s case record.
Item
Guidance
To be
completed
on RiO
Carers Care Plan
Complete all appropriate items for the Carers Care Plan
Yes
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D. Inpatient Management
1. Inpatient Management
Some inpatient services have a referral prior to admission and these admissions are not gate kept by CRHT
Teams. Details of the process and recording expectations for all inpatient services can be found in the ‘Best
Practice and Consistency of Recording in RiO - Inpatient Services’ document on the RiO pages of the
Intranet.
1.1 Inpatient Admission
The RiO inpatient admission screen must be completed at the time of admission with any missing or
updated information added as soon as it is known. Where an existing form is not covered in RiO and no way
of recording the information within the RiO forms has been found, a paper form may need to be completed
and scanned to the record. These should be limited to areas such as Waterlow scales etc. See Best
Practice and Consistency Document on the RiO pages of the Intranet or via the link below for details.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
The following table provides guidance on the information that must be recorded for all people using our
services as soon as it is available:
Item
Guidance
To be completed on RiO
Ward
Yes
Bay
Yes
Bed
Yes
Consultant
Yes
Referral source
Admission
date/time
Admission source
Admission method
Client classification
Intended discharge
date
Internal referral should be chosen for any
referral from within DPT e.g. CRHT.
Use ‘General Hospital – ward’ for re-admission
following overnight(s) admission to a general
hospital.
Must be recorded accurately, i.e. the time the
person was admitted to the ward, not the time
the admission was entered onto RiO. This
information is reported on as part of the Mental
Health Minimum Data Set national reporting
requirements.
Use ‘NHS – other hospital’ for re-admission
following overnight(s) admission to a general
hospital.
The admission method would be ‘Other means’
for gate kept admissions, ‘Planned’ for referral
based inpatient services or detox beds and
‘Transfer of any admitted client from other
hospital provider’ for those returning from PICU/
general hospital.
Usually Ordinary Admission.
Only to be completed on admission for planned
admissions e.g. detox beds.
Yes
Yes
Yes
Yes
Yes
Yes
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First in a regular
series
Consultant
speciality
No
Will pull through automatically (Where the
person is admitted for detox then select the
responsible consultant).
No
Other consultant
Optional
Intended
management
Decided to admit
date
Legal status on
admission
Yes
Date decision to admit made.
Optional
Indicates whether the person has been admitted
on a Section. This does not feed the Mental
Health Act Administration Module of RiO and
will not show on the person’s main case record
screen or the Ward Management screen MHA
Section(s) indicator.
Yes
Psychiatric patient
status
Administrative
category
Yes
Yes
Referral reason
The person using our services should be
recorded as ‘NHS patient, including overseas
visitors’. If the person using our services is not
from the UK, notify the Application Support
Team
This is the reason for admission
Referring HCP
Referring HCP is a drop down list
Yes
Named nurse
Yes
Yes
Initial assessment should be commenced within 4 hours of admission. Guidance on which areas of
the Core Assessment should be completed at this point is available in the Best Practice &
Consistency of Recording in RiO document on the Urgent & Inpatient Care page in the RiO section
of the Intranet. Guidance on recording in relation to CQUIN targets (e.g. VTE, Physical Examination
etc.) is also available on the same page of the intranet.
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
1.2 Inpatient Episode
The following table provides guidance for recording information for clients on RiO during their inpatient stay:
Item
Guidance
Planned leave –
planned date and time
Must be recorded as soon as the arrangements for the leave have been
confirmed and updated if circumstances change
Planned leave – actual The date and time the leave commences must be recorded
date and time
Planned leave – return
date and time
Section 17 Leave
The date and time a person using our services returns from leave must be
recorded – figures on leave are reported on as part of the Mental Health
Minimum Data Set national reporting requirements.
See Section C2 below regarding the recording of leave permissions in RiO
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Absent without leave
(AWOL)
See Missing Person Policy: C02 The procedures outlined in this
policy must be followed and the existing forms used and scanned
back to the record as required.
The AWOL option on RiO must only be used for people using our services
who are subject to a Mental Health Act Section. The date and time must be
recorded as soon as possible and the person’s risk assessment reviewed.
Figures on AWOL are reported on as part of the Mental Health Minimum
Data Set national reporting requirements.
Those admitted informally who are absent from the ward should be
recorded as being on home leave until a clinical decision is made to
discharge, Section, transfer, etc. A progress note should be added to the
person’s case record. The risk assessment should be updated if necessary
and appropriate action taken to safeguard the individual if they are felt to
be at risk/ of risk to others, in line with Trust policy/ professional practice.
This should be recorded in the progress notes and linked to risk.
RiO does not allow admission or transfer into a bed where the person is
marked as AWOL.
Sleepover
A person receiving care in one ward but using a bed in another ward must
be recorded as a sleepover
Transfer
Use to record persons moving between wards/units within the same
service within the Trust. It is the responsibility of the transferring ward to
complete the transfer on RiO following the transfer of the person. This
information is reported on as part of the National Mental Health Minimum
Data Set.
Where someone is admitted for at least one night to another hospital such
as the RD&E they must to be discharged in RiO and re-admitted when they
return. It is emergency readmissions that are reported on rather than
planned ones so the discharge to and admission from fields should indicate
that they went to and came back from a general ward. (see admission
guidance above)
This can be found within the admission record form and must be completed
in order for the delayed discharge icon to appear on the bed. This should
be completed once this date has been identified
Treatment at hospitals
outside of the Trust –
Ready for discharge
date
Delayed discharge
reason
Only one option can be chosen, ‘delayed – complete a delayed discharge
form’. These details must be completed.
RiO forms related to
inpatient processes
Folder Name
Guidance
Observation/ Fresh
Air/ Seclusion
Specialist assessments
Not currently in use – individual needs in this
area would be part of Care Planning.
Pre-discharge
planning
Care Planning, CPAs and
Reviews
Delayed discharge
Inpatient management
Includes 48 hour and 7 day follow up. To be
completed for all relevant inpatients. Inpatient
staff will need to inform community staff that
a follow up is required well in advance of
discharge where possible.
To be completed for all delayed discharges
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RiO Standard Operating Procedures
Other assessments
Progress notes
Core Assessment
Risk Information
See Progress Notes
Section
To be updated as relevant - see assessment
section for details.
To be used to record the ward round
summary/handover and any clinically
significant contacts. Progress notes must be
recorded for each inpatient at the end of each
shift and must be validated.
1.3 Discharging an Inpatient
The following table provides guidance on recording discharge information for people using our services
following their inpatient stay:
Item
Guidance
To be
completed
on RiO
Discharge
date/time
Must be the date/time the person was discharged, not the time
that this was recorded on RiO
Yes
Method
Select as appropriate
For temporary discharge to a general hospital for treatment,
use: 1. ‘Discharged on clinical advice or with clinical consent’
Select as appropriate
For temporary discharge to a general hospital for treatment,
use: ‘NHS Other hospital provider – ward for general patients’
If the destination ‘usual place of residence’ has been selected,
this does not need to be completed
Yes
Destination
Destination
address
Yes
Yes
A confirmed diagnosis needs to be entered by the Responsible Clinician (RC) prior to /at discharge from an
inpatient setting using Unfinished or Finished Consultant Episode as the event to link this to.
Currently the Discharge Summary Form is completed outside of RiO although information can be copied
and pasted from RiO to the form. This form is sent to the GP within 24hrs of discharge and should also be
uploaded to the record.
Where community follow up is required, this should form part of the Care Planning process and if there is no
current referral open one should be made as early in the admission as possible. (See Best Practice page of
the Intranet for a guide to creating a referral) 48 hour follow up is the subject of a CQUIN target with
financial implications for the Trust if not met. Guidance on recording in RiO to demonstrate that
these targets have been met is available on the Best Practice & Consistency page of the RiO part of
the Intranet along with guidance on all recording prior to discharge.
1.4 Delayed discharge
Delayed discharge should be recorded on the admission details screen (available via the ward bed view or
Inpatient Management). The delayed discharge form (under Inpatient Management in the case record)
should be used to capture the details and can only be completed after the admission details are updated.
Updating the Admission Screen:
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RiO Standard Operating Procedures
Item
Guidance
Ready for
discharge date
Reason for
discharge delay
Enter the date that it was decided the person was ready for discharge
Only one option available in the drop down menu ‘Delayed, please complete the
‘Delayed Discharge’ form’. Select this option and save.
Completing the Delayed Discharge form:
Item
Guidance
Date/ Time
Date/ Time the form is created
Inpatient Episode
Search for the current admission – this will only work if the admission details have
been updated as above.
Delayed Start
Date
Delayed End Date
Date the person was ready for discharge – should match what was entered on the
admission screen
Enter when known – should be the date this particular delay ended.
Reason for Delay
Select from the drop down list
Delay
Responsibility
Number of Days
Select from the drop down list
End Reason
Select from list – to be completed when all delays to this specific discharge end.
Comments
Any additional information required.
Number of days delayed – enter when known. Click ‘Add’ to save these details.
Another line will then appear where a second reason or period of delay can be
recorded.
1.5 Death of Inpatient
If a person using our services dies during an inpatient stay complete a Datix incident form and this will
cause the details will be sent to the Applications Support Team immediately.
The person using our services must be discharged and the discharge method ‘client deceased’ selected.
The Application Support Team are the only people who register death on RiO.
1.6 Ward Attenders
People who attend a ward for care / treatment, but are not currently admitted to a bed in the Trust should be
recorded on RiO as a Ward Attender. At present this refers only to the eating disorder service.
2. Medicines Recording
The RiO Prescribing module is not currently being used.
At the point of referral, current medication should be recorded in the Current Interventions including
medication box of the Presenting Situation & Referral Outcome Decision form in the Core Assessment.
For inpatient services, current medication is recorded on the medicine chart and this is scanned into the
record when complete or at discharge. Use of medication should be included in Care Planning but the
medicine chart is the definitive record of type, dose, administration etc.
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RiO Standard Operating Procedures
Medicines reconciliation should be carried out in line with MM25 Medicines Reconciliation Process which
can be found under Medicines Standard Operating Procedures in the Policy & Procedure section of the
Intranet or via the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11473&m=0
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RiO Standard Operating Procedures
D1 Section 17 Leave
Guidance for RC giving formal Section 17 leave permissions on RiO
1. From the case record screen choose Care Planning. If there is a Care Plan entitled “Section 17
leave permissions” open this and update it (see paragraph 5 below).
2. If there is no existing plan entitled “Section 17 leave permissions” set one up by clicking ‘Library’ at
the bottom of the Care Planning screen.
3. Enter ‘Sec 17’ in the Search text box and click
down list Library Problems / Needs and click
.
Then select ‘Sec 17 Leave’ from the drop
1002932
.
4. In the Care Plan Library screen, tick the box to select the intervention and then click save. This will
pull the library care plan into the individual’s case record and the intervention can be edited to
include the correct permissions and conditions (additional interventions can be added as required)
The ‘Authorised by’ and ‘Main Person Responsible’ boxes can be left blank. This care plan is only
valid if set up by the RC and staff will be able to see the RC name by clicking
.
5. To alter an existing leave permission, highlight the Intervention in the Care Planning screen and click
“edit selected” then edit the leave remembering to enter the start and end times. This will then allow
leave permissions and carries your name and the time it was entered. (Changes can be seen by
clicking ‘Display Edits’)
6. When the person goes on or returns from leave, this should be recorded on RiO via the bed view.
This retains a record in RiO of all leave taken (including Section 17) which can be viewed in the
leave history and reported on as part of the National Minimum Data Set.
PN 30 June 2011 Revised Oct 2011
Guidance for ward staff on checking Section 17 leave permissions on Rio
1. From the case record screen choose Care Planning. If leave has been set there will be a Care Plan
entitled “Section 17 leave permissions” click on the right hand down arrow to open interventions.
2. Any leave set will be described as an intervention. Check that the person who has written or updated
the intervention is the RC and the start and end dates and times.
3. If there is any doubt or ambiguity for instance if two apparently conflicting permissions seem to have
been set then check with RC before allowing leave (this should not happen if the RC has followed
guidance in using RiO to allow leave).
PN 30 June 2011 Revised Oct 2011
Guidance on printing a copy of Section 17 leave permissions from RiO when
required
The Code of Practice states that copies of Section 17 leave permission should be given to patients and
carers. This can most easily be achieved by obtaining the “Care Plan Point in Time” view from “Client
Related Data-Views” copying and pasting this to a word document and deleting the parts of the Care Plan
which are not required before printing it out. Here is an example:
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RiO Standard Operating Procedures
Name
Mr Xxx Xxxxx Xxxxxxxx (XXXXXXX)
Admission Date
28 Apr 2011 19:30
Ward
Coombehaven
Problem
Intervention
/ Actions
and
Frequency
Section 17 leave permissions
Up to one
hour
unescorted
once a day.
12 May
2011
11:03
18
May
2011
17:00
Up to two
hours
accompanied
by Mother
into Exeter
12 May
2011
11:05
19
May
2011
17:00
To be valid must be completed by RC
and be in date
Leave is granted at the discretion of
the nursing staff and dependent on
current mental state
Anticipated Authorised Main
Outcome
By
Person
and Clients
Responsible
View
Planned Actual
/ Actual End
Start
Date
Date
PN 30 June 2011 Revised Oct 2011
Out of Hours
The advice from CQC is that if S17 leave is granted by the acting RC out of hours, then whoever has the
conversation with the RC gets faxed/email written agreement, records this onto a RiO progress note linked
to and referencing Section 17 Leave Care Plan using the words authorised by and naming the RC. It can
be a nurse or doctor that records this onto RiO. The email or fax should be uploaded to the documents
under MHA Documents.
When the RC is next on duty he/she should then confirm the granting of S17 leave on RiO stating the date
and time that he/she granted this.
This is an interim process until all consultants have access to RiO remotely via their work laptops.
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RiO Standard Operating Procedures
E. Referral Management: Triage, Allocation, Transfer and Discharge
1. Recording Referrals
All referrals must be recorded on RiO even if considered “inappropriate” as this will reflect the number of
referrals made to teams and the impact on resources used to manage the referrals.
1.1 Managing Referrals between DPT Teams
Please see the grid in Section E1 for details of when to create a new referral in order to refer to another
DPT service and when to transfer the existing referral to another team. The grid also identifies when
referrals cannot be made e.g. only RIL can refer to Community Rehab, Russell Clinic and AOT. MWA would
have to transfer their existing referral to RIL first.
Both internal referral and transfer require staff to adhere to the following:
 Referral/transfer requires a verbal or written clinical communication between referrer and the
receiving team regarding the nature and reason for the referral.
 A note of the referral/transfer should be entered into the progress notes.
 HCP Referred to must always be left as ‘none’ when making or transferring a referral
 Referrals/transfers are pushed to a team, i.e. the referrer makes the referral/transfer in RiO to the
receiving team.
Where an internal, parallel referral is made to a specialist service, the existing referral may remain open and
if it does, the recovery co-ordinator would retain overall responsibility for the person’s care.
Referrals are opened in RiO through the Client Referrals - Entry/Exit Screen.
You also access the transfer option through the referral entry/exit screen. On the referral in question you
click on the ‘Transfer” hyperlink. This opens a dialogue box and you complete the required fields here,
always leaving the ‘HCP referred to’ field as none. This transfers an existing referral from one team to
another and it goes into the Lead HCP caseload unallocated. This effectively closes the referral in one team
and opens it in another without having to discharge the referral and create a new one. Referrals should only
be transferred within the same specialty (e.g. from one Adult Mental Health Service to another, not from
Adult to Older People’s Mental Health Services)
The term Rapid Re-referral must no longer be used. Plans for future access to services should form part
of the Crisis, Relapse & Contingency plan within the Care Planning function of RiO prior to discharge. This
plan should include who to contact and how (Mental Wellbeing & Access/ Crisis Resolution & Home
Treatment) and if permission is granted by the individual, copies can be supplied to the GP and carers for
their reference. The contingency plan will remain in RiO post discharge and can be accessed when a new
referral is made to DPT.
1.2 Completing the New Referral Form
Item
Guidance
Referral Date
Time
This is the date the referral is received by the team for external referrals i.e. date
stamped and must be recorded as it is used to calculate waiting times. (Enter the
time the referral was received if known or 09.00 for MWA/RIL. The exact time is
more crucial for CRHT who are required to see people within either 4 or 24 hours)
For internal referrals it is the date and time the referral is being opened.
Select Adult Mental Illness for most services. Old Age Psychiatry for OPMH,
Learning Disability for Learning Disability teams. The selection at this point will
determine the options available in some of the following drop down menus.
Service Group
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RiO Standard Operating Procedures
Service
Care Setting
Referral Source
Referral Reason
If you selected Adult Mental Illness in the Service Group box above, the options
here will be: Adult Mental Illness, Eating Disorder, Liaison Psychiatry, Perinatal or
Psychotherapy. If opening a referral to any Psychology & Psychological Therapies
team, use Psychotherapy in this box. If you selected Old Age Psychiatry or
Learning Disability, you will only have one option in this field.
Select from list. (Usually Community Team)
Select from list. The options available will depend on choices made regarding the
service and service group.
Select from list.
Team Referred To Should relate to the Service and Service Group above – select the relevant team
HCP Referred To
Referral Urgency
Administrative
Category
Referral
Comment
Date on the
Referral
Letter/Form
Referral Date
Accepted
Do not complete this field. The referral will then default to the Lead HCP case load
and the Team Caseload as an unallocated case.
If you have an administrative role, the urgency must always be set to “Pending”.
The appropriate urgency can be set following triage and prior to booking an
appointment (it cannot be changed once an appointment is booked).
Emergency (CRHT Only) – to be seen within 4 or 24 hours (indicate which by
using one of the following codes in the referral comments box: ‘##4hrs’ or
‘##24hrs’)
Urgent –to be seen within 5 working days
Non-Urgent –to be seen within 28 days.
People who use our services should be recorded as ‘NHS patient, including
overseas visitors’. If the person is not resident in the UK, contact the Applications
Support Team (01392 675679) or DPT.servicedesk@nhs.net
Uses: For internal referrals, record who the referral was discussed with in the
referred to team, and if required, which part of a service is being referred to e.g.
South Devon Psychology – Older People’s.
For external referrals: Record the GP name if it is not possible to record the correct
name elsewhere on this form.
Enter date if the referral was received in this form. Leave blank for telephone
referrals and referrals made directly in RiO.
This needs to be completed after triage/referral screening.
This is the date the decision is made to accept the referral. This must be recorded
as it is used to calculate waiting times
2. Triage
This is the process of referral screening done by an HCP prior to an initial appointment. The Referral
Screening form in the Client Referrals folder on the case record should be used. This form is used to record
whether the referral was appropriate or inappropriate.
Following triage, Clinical staff will complete referral screening outcomes via Client Referrals - Referral
Screening.
Item
Guidance
Referral
Select the appropriate referral
Result of
Screening
Select from:
 Open – Appropriate referral
 Close – Inappropriate referral
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RiO Standard Operating Procedures
The clinical rationale for this decision should always be recorded in this form.
In addition, the Date Accepted must be completed in the Entry/Exit Screen (as above).
Where a referral is deemed to be “inappropriate” it is not appropriate for DPT services. However the person
may be signposted to appropriate external services/agencies. This will require the referral to be discharged
with a discharge reason of “inappropriate referral”.
All appropriate referrals will remain on the nominated Lead HCP’s caseload unless / until allocated to an
HCP.
3. Allocation to HCP
The Lead HCP for a team allocates cases to an HCP within that team when intervention /treatment is about
to start or at the point of assessment depending on agreed protocols (See Best Practice Guidance). Once
allocated, a person cannot be ‘un-allocated’ they can only be transferred. Where the person remains open
to the team for medication review only, they should be allocated to the prescribing psychiatrist and the
referral to the team should remain open. AMHP teams only allocate for CTO/ Guardianship/ ongoing follow
up work NOT for MHA assessments. CRHT do not allocate but work from the team caseload. Team specific
guidance is available in the Best Practice & Consistency of Recording in RiO documents:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
3.1 Sharing a Caseload/Cases
Within the caseload transfer function of RiO is an option to share a caseload or individual cases. This is only
possible with cases allocated to the person doing the sharing and they can only share within their team. The
purpose of this would be to identify where two members of the team are working with the same individual
over a period of time. The benefit would be that the person shows on both caseloads. A case or caseload
can be shared with more than one person. Appointments booked by one person do not appear in the other
HCP’s diary unless the other HCP is added to the appointment when it is being made – shared caseload
makes no difference to this. If the referral is discharged, it will be removed from all of the caseloads within
that team if it had never been allocated. It will show as discharged on the case loads of all those it was
allocated to hwere it had been allocated prior to discharge.
4. Discharging from Recovery/Care Coordinator/ HCP caseload
People who use our services must be discharged when there is no further input needed from any member
of the team. The duty to discharge a person from a service is the responsibility of the allocated HCP(s) in
liaison with the Lead Healthcare Professional/CTL. Care should be taken that no other team members
including Psychiatrists have future appointments with the person as discharging the referral will cancel
these. Where the team psychiatrist intend to see the person in outpatients but no other team members are
involved, the person should be transferred to the Psychiatrist’s caseload and the referral left open.
It is the responsibility of all HCPs to ensure their caseloads are up-to-date and that people are discharged
appropriately. Discharging a client and removing their name from the individual caseload will not remove
their details from RiO, their case record will still exist. A subsequent new referral to the team can be made
at any time if appropriate.
When discharging, the following must be completed:
 Outcome all appointments
 Ensure progress notes are up to date and validated
 Closure of all Care Plans and interventions for that element of care
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RiO Standard Operating Procedures

Enter the end date for the Care Cluster on the Cluster Allocation form (if discharging from DPT –
the cluster will remain in place if the person continues to be seen elsewhere in DPT)
 A CPA discharge review must be held in order to discharge from CPA (if this is not done the person
will remain on the Care Co-ordinator’s case load even if the referral is discharged)
 Discharge the referral via the Referral, entry/ exit screen
If the HCP is also the CPA Care coordinator for the person, then they must complete a CPA review (with the
review type is set to discharge review) before discharging the referral in order to remove the person from
their caseload. Failure to do this will mean the person remains on their caseload for CPA care coordination
even though the referral is discharged.
If a member of staff leaves, their case load, particularly where they are the CPA care coordinator must be
re-allocated. If this is not done, anyone that remains on their individual case load will be re-allocated to the
Lead HCP by the Application Support Team when they are notified that the person has left. The Lead HCP,
Service Manager and Managing Partner relevant to the team will be informed when this is done.
NOTE: the Application Support Team are notified of leavers on a monthly basis so it may be 3 weeks after
someone has left that they become aware of the situation.
4.1 Discharging from Section 117
Discharging a person who was on a Section 117 requires the completion of the Section 117 form and the
agreement of Health and Local Authority, it is not the HCP’s decision alone and if any services continue to
be provided, the Section 117 responsibility must be transferred.
5. Death of a Community Client
If a person dies whilst under the care of a community team, the team should discharge the person from their
caseload, selecting the discharge reason ‘client died’ and complete a Datix incident form. This will be
forwarded to the Application Support Team who will record the death in RiO. If you have any queries
regarding this please contact:
Application Support Team (01392 675679) or DPT.servicedesk@nhs.net.
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RiO Standard Operating Procedures
E1 – Team Transfer Options (See notes below)
FROM
Services
CRHT
Inpatients
(Adult)
W&A
STEP
Psychological
Therapies
R&IL
AOT
Rehab
community
Permitted
Inpatients
External Discharge
referral from DPT CRHT (Adult) W&A
transfer refer
Yes Yes
refer
STEP
refer
TO:
refer
refer
refer
No refer
refer refer
refer refer
refer refer refer
refer refer refer
refer refer refer
refer
refer
refer
No
No
No
refer
refer
refer
Psychiatric Forensic Link
EDU
Inpatients AST
Rehab Rehab Vocational OPMH Inpatients
Psychological
Therapies R&IL AOT community inpatients services CMHT (OPMH) EDI (LD) (LD) Gender inpatients Perinatal Liaison inpatients Services IPP
refer
refer refer refer No refer refer refer refer refer No
No
refer No No
No
refer
refer
refer
refer No
transfer No
transfer No
refer
refer
refer
transfer
No
No
No
transfer
refer No
refer No
No
No
No
Yes
Yes
Yes
refer No
transfer refer
refer
No
Yes
Yes
refer
refer
refer
refer
No
refer No No
transfer transfer transfer refer
transfer transfer refer
No
No
No
transfer
refer
refer
refer
refer refer
transfer transfer refer
transfer transfer refer
refer refer refer
refer refer refer
refer refer refer
No
No
No
refer refer
refer refer
refer refer
refer
refer
refer
refer
refer
refer
Yes
Yes
Yes
refer
refer
refer
refer
No
No
No
transfer refer
refer
transfer transfer
No
transfer transfer refer
refer
No
refer refer refer
refer
refer
refer refer
Yes
refer
refer
No
refer
refer refer
refer refer
refer
transfer transfer transfer
refer
refer
refer
No
transfer transfer refer
No
refer refer refer
refer refer refer
refer refer refer
refer refer
refer
refer
refer refer
refer
No
No
No
refer refer
refer
refer
refer refer
refer refer
refer refer
refer refer refer
refer
No
No
refer
refer
refer
refer
refer
refer refer
Yes
No No
refer No
refer
transfer
refer
refer
refer
refer
No
refer
No
refer
No
No
refer
refer
refer
refer
No
No
refer
refer
refer
No
No
No
No
No
refer refer refer
refer
refer
refer
refer
No
No
No
No
No
No
refer refer
No
No
No
No
No
No
No
No
No
No
No
refer
refer
No
refer
refer
refer
refer
refer
refer
refer
refer
refer
refer
refer
refer
refer refer refer
No
No
No
refer refer refer
refer refer refer
Yes
Yes
refer
refer
refer
refer
refer
refer
refer
refer refer
refer
No
refer
refer
refer
refer
refer
No
refer
refer
refer
refer
refer
No
refer
refer refer refer
No No No
refer refer refer
No
No
No
No
No
No
refer
refer
refer
refer
refer
refer
No
refer
refer refer
No No
refer refer
refer
refer
refer
refer
refer
refer
refer
No
refer
No
No
refer
refer No
refer
refer
No
refer
No
No
No
No
No
No
refer
refer
refer
refer
refer
refer
refer
No
refer
No
refer
refer
refer
refer
refer
refer
refer
Yes
Yes
Yes
Yes
Yes
Yes
refer
No
refer
No
refer
refer
refer
refer No
refer
No
No
No
No
refer
No
No
No
refer
refer
refer
refer No
No No
refer No
No
Yes
refer
refer
No
refer
refer
No
refer
No
refer
No
refer
refer
No
refer
refer
Yes
refer
No
refer
No
refer
refer
No
refer
No
Yes
Yes
No
Yes
No
No
Rehab inpatients No
Vocational
services
Yes
OPMH CMHT Yes
Inpatients
(OPMH)
Yes
EDI
Yes
Inpatients (LD) No
AST
Yes
Gender
Yes
EDU inpatients Yes
Yes RD& E
Yes RD& E
Perinatal
Psychiatric
Liaison
Forensic
inpatients
Link Services
IPP
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RiO Standard Operating Procedures
E2 Internal Referral/ Transfer Notes
Inpatients Services
A referral is only required for Eating Disorder Service, Rehab inpatients (Russell Clinic), and Forensic
Services. For unplanned admissions to Adult inpatient services, there must be an open referral to the Crisis
Team until the admission is completed in order to demonstrate that the admission went through a gate
keeping process.
Vocational Rehabilitation Services
Workways in Exeter do not accept referrals from services; access to their service is by self-referral/
application. See Workways website for details.
Standard Operating Procedures V5
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RiO Standard Operating Procedures
F Assessment: 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.
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
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RiO Standard Operating Procedures
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.
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
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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
Use
This form is only used when problematic substance and alcohol use has
been identified.
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.
Mental Health
History
Physical Health
History
Personal & Family
History
Social History/ Care
Management
Mental State
Examination
Physical
Examination
Physical Health
Assessment
Physical Monitoring
Nutrition
Body Map
Annotation
Client and Carers
understanding of
assessment
Formulation/
Summary
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.
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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
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.
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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?
Safeguarding
Forms
Risk Information
Risk incidents
Risk information
HCR-20
Risk Information
Observations
Risk Information
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.
See Safeguarding section for details.
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
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MOHO OT Assessment
Includes:
ACIS
MOHOST
OCAIRS
Occupational Self
Assessment (OSA)
Summary
- OPHI-II
- VQ
- WEIS
- WRI
NCDS
These should only be completed by appropriately trained Occupational
Therapists as required. Always create new.
-
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
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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RiO Standard Operating Procedures
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-practiceguidance/mca-pg31.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
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
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Reason for
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 the uploaded documents including the document title and date where these
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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G. Safeguarding
NOTE: It has been agreed with the relevant Leads across Devon/Torbay that minutes of Safeguarding
meetings should be scanned and uploaded to RiO. Minutes of Child Safeguarding meetings should be
uploaded under document type Meeting Minutes/ Notes, Minutes of Adult Safeguarding meetings should be
uploaded under document type Safeguarding Vulnerable Adults.
1 Safeguarding Children
This guides the recording of safeguarding issues in RiO – reporting and other actions should be
taken in line with the Trust Safeguarding Children policy (C25 – link below) and direct
communication with colleagues is still required. Consideration should be given to completing a
Datix incident form in relation to safeguarding in line with Datix guidance.
http://nww.devonpartnership.nhs.uk/default.asp?a=8427&m=0
As part of the initial assessment process, it is important to record family details particularly children for
whom the person using our services 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. Risk should be considered not just in terms of
known offenders but also in terms of the impact of mental health issues in the family on the children
involved.
Item
Guidance
Where to record
Dependants
All dependent children should be recorded. ‘Dependant’
must be selected as the ‘type’ of contact for the
information to appear on the front of the case record.
Unborn children should be recorded with ‘Unborn’ in the
family name box and due date recorded in the comments
box. This should be updated with the child’s name etc.
after the birth.
This can be recorded in a number of places depending on
the point at which the information is gathered. It should
always be clearly recorded in the Risk Assessment. Risk
to children would include risk to an unborn child where the
client is pregnant.
Record the family picture including any children of the
client or their immediate circle with who they have regular
contact. Indicate if partner is pregnant.
Client Personal
Contacts
(demographics
screen)
Additional
Support
required to
parent
children
Forensic
History
This requires a yes/no answer and details to be written in
the comments box. A ‘Yes’ would prompt the completion of
the Safeguarding Children – Adult Client, Form 1
Social History / Care
Management (Core
Assessment)
All offending history to be recorded here including offences
against children
Safeguarding
concerns
identified
Identify the concerns regarding safeguarding and where
known, the identity of the child(ren) this relates to. This
should be completed as fully as possible. Where the child
is unborn or not yet named, the given name should be
recorded as ‘Baby’.
Forensic & Probation
History (Core
Assessment)
Safeguarding Children
– Adult Client, Form 1
(Risk Information)
Risk
Relationship
to children
Risk Assessment
(Risk Information)
Referral Screening
(Client Referrals)
Personal & Social
Information (Core
Assessment)
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In contact with
child(ren) on a
Child
Protection
Plan
The person
using our
services is a
child on a
Child
Protection
Plan
Risk
Management
Plan/ Care
Plan
Contingency
plan
Information
from contacts
with the
person using
our services
Details of the safeguarding issues that have lead to the
child/ren being on a Child Protection Plan should be
entered here. These are likely to come from safeguarding
meetings and the source of the information should be
identified. NOTE: it is not possible to put ‘no’ against this
on the front of the case record – it will either show as ‘none
recorded’ or as ‘Yes’.
If the person using our services is under 18 and in full time
education and is subject to a child protection plan, this
form should be completed as fully as possible with the
source of the information identified.
Safeguarding Children
– Adult Client, Form 2
(Risk Information)
Care planning should include risk management and the
appropriate problem/ need type should be selected so that
progress notes can be linked to the care plan.
Care Planning (Care
Planning, CPA &
reviews)
Details of who will care for dependants in the event of
admission or other circumstances where the person
themselves is no longer able to do this must be recorded.
This will only be in Safeguarding Children – Adult Client
Form 2 where a Child Protection Plan is in place.
Crisis Relapse &
Contingency Plan
(Care Planning, CPA
& reviews)
Safeguarding Children
– Adult Client, Form 2
(Risk Information)
Information from contact with the person is generally
recorded in progress notes and any safeguarding
concerns should be documented urgently. Information may
also need to be entered into specific forms as detailed
above. Progress notes should be linked to risk, significant
events and care plans as appropriate.
Progress notes
Safeguarding Children
– Child Client (Risk
Information)
2 Safeguarding Adults
The Trust has a responsibility as part of its registration requirements with the Care Quality Commission to
safeguard people who use our services from abuse. The Trust has been keen to support the introduction of
a central referral point for safeguarding alerts which is already established in Torbay. The Trust has been
working with Devon County Council to ensure a consistent approach is undertaken across the rest of Devon
and a new process was introduced on 25th October 2010.
Guidance on the new process, the introduction of a Safeguarding Alert Form, as well as the Torbay process
is available in the Safeguarding Adults section on the Trust intranet at http://nww.devonpartnership.nhs.uk
Click Safe Services on the left hand menu.
Visit the website below for further information.
http://www.devon.gov.uk/index/socialcarehealth/older_people/adult-protection.htm
As with safeguarding children, the guidance below 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 (C19 Safeguarding Vulnerable Adults) and good practice guidance. Reference
should be made to the Safeguarding Alert process and forms. Where a referral to the Safeguarding Team at
DCC/Torbay is made regarding a person who uses our services, the form should be saved to the case
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record and a note made in the progress notes. Any management plan arising from this referral should be
incorporated into the care plan.
Consideration should be given to completing a Datix incident form in relation to safeguarding issues in line
with Datix guidance.
Link to C19 Safeguarding Vulnerable Adults
http://nww.devonpartnership.nhs.uk/default.asp?a=8427&m=0
Link to safeguarding information:
http://nww.devonpartnership.nhs.uk/default.asp?a=11212&m=0
Item
Guidance
Where to record
Dependants
All dependent adults should be recorded. ‘Dependant’
must be selected as the ‘type’ of contact for the
information to appear on the front of the case record.
Issues regarding dependants should be recorded in the
Mental Health Legislation /Protection of Vulnerable Adults
form. Select ‘no’ against Client on Adult Protection
Register in order for this to show on the front of the case
record.
This can be recorded in a number of places depending on
the point at which the information is gathered. It should
always be clearly recorded in the Risk Assessment. This
should be used to record risk of harm from others including
domestic violence and risk of harm to others including
vulnerable/ dependent adults / children. The level of risk
should be identified in the summary box.
Record the family picture including any relationships that
cause concern that either the person using our services is
at risk or poses a risk to another.
Client Personal
Contacts
(demographics
screen)
Mental Health
Legislation /Protection
of Vulnerable Adults
(Core Assessment)
Risk Assessment
(Risk Information)
Referral Screening
(Client Referrals)
History of
abuse
Enquiry regarding experience of abuse (current or historic)
should be a routine part of clinical assessment. Please
note that this information is not visible on the core
Assessment overview.
Personal & Social
Information (Core
Assessment)
Financial
abuse
This may include abuse by someone with legal powers
over the person’s affairs.
Social History / Care
Management (Core
Assessment)
Physical
Abuse
Where injuries are reported/ observed. In a domestic
abuse situation where there are also children, child
safeguarding will also need to be considered and recorded
– see previous table.
All offending history to be recorded here including offences
against people
Body Map
Annotations (Core
Assessment)
Risk
Relationships
Forensic
History
Risk
Management
Plan/ Care
Plan
Care planning should include risk management and the
appropriate problem/ need type should be selected so that
progress notes can be linked to the care plan.
Personal & Social
Information (Core
Assessment)
Forensic & Probation
History (Core
Assessment)
Care Planning (Care
Planning, CPA &
reviews)
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Contingency
plan
Details of who will care for dependants in the event of
admission or other circumstances where the person
themselves is no longer able to do this must be recorded.
Crisis Relapse &
Contingency Plan
(Care Planning, CPA
& reviews)
Information
from contacts
with the
person using
our services
Information from contact with the person is generally
recorded in progress notes and any safeguarding
concerns should be documented urgently. Information may
also need to be entered into specific forms as detailed
above. Progress notes should be linked to risk, significant
events and care plans as appropriate.
Progress notes
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H. Appointment Management (Recording Contacts)
1. HCP Diary / Clinics
Generally, appointments are managed through the RiO HCP diary. Clinics are used for groups, duty and
initial assessment slot systems and traditional outpatient clinics where these are the preferred way of
working. Clinics can only be set up by the Application Support Team and 14 days notice is required. Groups
can be recorded in the HCP diary by adding all the people who use our services to the same appointment
and some services may prefer this way of recording group activity. All appointments made for a particular
person who uses our service can be viewed in the client diary (Client Related Data Views – see 1.4 Patient
Appointments and Contacts)
All community/ clinic based face-to-face and significant telephone contacts with people who use our
services must be entered as appointments in RiO and an outcome recorded. Only outcomed appointments
will be counted as contacts. It is the responsibility of each HCP to ensure their RiO diary/ clinic is kept up-todate although administrators/medical secretaries can book and cancel diary and clinic appointments on their
behalf. All HCPs including medical staff will be expected to treat their RiO diary as their primary source for
recording contacts with people who use our services.
HCP’s, including medical staff, need to enter the outcome of their community or clinic contact with people
who use our services, within 24 hours. Clinical information regarding the contact needs to be recorded in
the person’s progress notes. The notes can be dictated in if necessary with the originator changed to the
person dictating the note. The note then needs to be validated by the originating HCP once they have read
them and are satisfied that they are correct/ have made any corrections.
Other staff within a team can be given access to view the diaries of their colleagues, and can be authorised
to book in appointments on their behalf as part of the way the team is set up by the Application Support
Team. Staff should not book into the diary of others without their prior agreement. This is also true
when arranging joint appointments – with the person’s consent, you can add them to your appointment and
this will then appear in their diary. RiO will indicate when you are booking an appointment if there are any
existing appointments which clash with the one you are booking.
It is also important to record when appointments are cancelled for whatever reason. This information is
retained by the system and can be reported on if required.
Carer’s do not need a referral themselves in order for appointments with them to be recorded in the RiO
diary so long as they have a Carer’s record (see Carer Records section).
As with current practice contacts/appointments can be recorded in the RiO diary retrospectively.
CPA reviews must be booked through the Care Planning, CPA and Reviews section of the case
record. This is essential as outcoming the CPA review takes you to the screen where details of the review
such as what is working well etc. are recorded. This feeds through to the printable Care Plan.
Recording of phone calls in RiO
Phone contact with a person using your service should be recorded in the progress notes. There is no need
to record a phone call which sets up an appointment unless there was other content to the call that requires
recording. This is because the appointment itself will be booked into RiO and visible on the patient / HCP
diary.
Where phone contact is clinically significant it should be recorded as an appointment in the HCP diary. It is
important to un-check the face-to-face box on the appointment screen and to indicate that it is a telephone
appointment.
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The following table provides guidance for recording contacts on RiO:
Item
Guidance
Where to
record
RiO diary
Location
Always select the location where you are from the list –
additions can be made to this list via the Application
Support Team.
Group appointments
Including Day Therapy attendances. To set up a new
therapy group as a clinic, System Administration will
need to be contacted with 14 days notice.
Client face-to-face
contacts in a clinic
setting
Inpatient contacts by
community HCPs
Primarily used for initial assessment ‘slot’ system and
other appointment systems as agreed locally.
RiO diary or
clinic if this
has been set
up for the
team
RiO diary or
clinic if this
has been set
up for the
team
RiO clinic
Inpatient contact by
inpatient staff
Unless clinics are used for group activity, appointments
are not used to record contact in inpatient settings.
Clinical information from a contact or observation should
be recorded in the progress notes.
Client community faceto-face and telephone
contacts in a non-clinic
settings, including all
therapy contacts
RiO diary
Progress
notes
1.1 Other Activity
The diary also allows the recording of the following:
Item
Guidance
Indirect client activity,
e.g. supervision
contacts, team
discussion
The time for the meeting can be entered into
Clinical decisions or
the diary using ‘meeting’ from the drop down
other clinical
list and identifying the type of meeting in the
information arising from
comments box. Clinical information should be
these meetings needs
added to the progress notes but a contact
to be recorded in the
should not be entered.
progress notes.
It is not mandatory for staff to record this information on RiO but it may be
useful to indicate availability or otherwise. Please note: RiO does not
recognise Bank Holidays and if these are not available for appointments,
they would need to be blocked out using the leave option.
Non-client activities:
• Absent
Where to record
• Leave
The comments box can be used to identify the detail of the activity.
• Meeting
• Training
Staff should continue with current practice but can use RiO in addition to
this. RiO will not link with Outlook diaries and PDAs
• Travel
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1.2 Appointment Types
All contacts recorded on RiO are marked as “face to face” (default option) unless this box is unticked. Not all
appointment types will be available for all appointments e.g. for Out Patient clinics, the only available
appointment type will be ‘Generic appointment’.
The following table provides guidance for selecting appropriate appointment types in RiO:
Appointment Type
Guidance
First Appointment
To record a person using our services or carer’s first face-to-face
appointment or clinically significant contact (except where this is an initial
assessment – see below)
To record any further face-to-face appointments / clinically significant
contacts with a person using our services or carer
Follow-up appointment
CPA Review
To record formal CPA and Care Planning reviews
Telephone contact
To record any significant telephone care contacts with a person using our
services or carer/s. These must be judged to be clinically relevant.
Cancellation of appointments should be regarded as significant.
Unplanned contact
This refers to any contact that arises in an unplanned way but may often
be urgent or involve crisis management.
To record the follow up contacts that must take place for high risk people
discharged from inpatient units when these are carried out by community
staff.
To be used to record follow up contacts which must take place for all non
high risk people discharged from inpatient units.
48 hour follow up
contact
7 day follow up contact
Community
No specific guidance
Follow up assessment
Use for any assessment other than Initial Assessment
Generic Appointment
No specific guidance
New Patient
Assessment
Review
Use for Initial Assessment only for people referred from an external
source.
Any Non-CPA review session
Standard
No specific guidance
Treatment
Appointments for the purpose of delivering intervention
1.3 Recording an Outcome from Contacts/Appointments
An outcome must be recorded following each contact/appointment, otherwise they will not be counted. The
following table provides guidance for recording a diary/clinic contacts/appointment outcome on RiO:
Item
Guidance
When to record
Activities
The relevant activity(s) must be recorded against each
contact/appointment prior to recording and saving the
outcome of the appointment:
 Further Assessment
 Initial Assessment
 Provision of Care
 Review
When recording an
outcome following a
diary/clinic contact/
appointment
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These will appear in the Client Dairy and indicate to others
the purpose of the appointment.
Item
Arrival time
Seen time
Outcome
Guidance
The ‘arrival time’ should be recorded correctly if known, or
as the appointment time if not known (NOTE: if the
appointment is DNA, enter this in the outcome box first and
the arrival and seen time boxes will blank out.)
The ‘seen time’ should be recorded as the time the person
was actually seen by the HCP
When to record
When recording an
outcome following a
clinic appointment
Select the most appropriate outcome description. The
clinical outcome of an appointment should be recorded in
the progress notes including DNA and the actions taken in
response.
When recording an
outcome following a
diary/clinic contact/
appointment (see
arrival time above)
When recording an
outcome following a
diary/clinic contact/
appointment
1.4. Client Appointments & Contacts
The Client’s Diary in the Client Related Data View of the Case Record allows you to view all appointments
for that particular person including those that have been cancelled or outcomed. The date range viewed can
be changed as required but the default is for appointments for the next month from the date viewed.
1.5 Recording DNA
Where the person who uses the service DNAs the appointment, it needs to be recorded in the outcome and
staff need to refer to the C03 Policy on Non-Attendance for subsequent actions. Cancellations should not be
recorded as DNAs – the appointment should be cancelled by clicking on the appointment time and clicking
cancel in the appointment screen.
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H1 - Use of Consultation Clinic to record contact by duty Doctors/
Consultants on call.
A number of locality related consultation clinics have been set up in RiO for this purpose. They do not
require the person being seen to have an open referral to DPT and should be used by all Doctors to record
contact when they are on call/ duty.






In order to record contact in the consultation clinic, you click on the diary icon at the top of the
screen and select ‘clinic appointments’ from the drop down list.
You select the relevant consultation clinic for the area you are working in and click go.
Select the date and click go.
You will then be in the appointment screen and you book the appointment in the same way as you
do in the diary by clicking on the appropriate time on the left of the screen and searching for the
person.
You may need to search the national system if the person has not been seen in DPT since RiO was
implemented.
If you are unable to find the person through the search, continue on paper and contact the
Application Support Team at the earliest opportunity. The information will need to be transferred to
RiO as soon as possible.
If you are unable to see the clinics in the clinic appointment screen, you have not been ‘linked’ to the clinic
by the Application Support Team. Please contact them on 01392 675679 or via email on
DPT.servicedesk@nhs.net
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I. Progress Notes
Each individual HCP is responsible for making relevant entries into the progress notes. If clinical information
cannot be typed directly into RiO, it should be written on paper or dictated for input into RiO at a later time.
Any paper notes should be shredded and not kept as this would be a data protection risk for the HCP, the
person using our services and the Trust.
The date and time at the top of the progress note screen must be changed to the date and time of
the appointment in order to sort the notes chronologically and to be able to link the notes to an
appointment. The system will automatically record when the note was actually entered. You can
record at the beginning of the note that this is a transcription of a contemporaneous note if this is
required. All outcomed appointments should have an associated progress note with the same date
and time and this will be reported on by the Performance team.
The progress note screen allows you to select the timeframe over which you view the progress notes. The
default is set for 3 months and if this is changed, the change will become the default for any other progress
notes you view in that session. It is recommended that you return the default to 3 months before exiting the
progress note screen you are viewing. This can be done by selecting ‘last 3 months’ from the drop down
menu and selecting the tick box then click ‘filter display’. This clears all filters applied to that screen.
1. Progress note entries
The progress notes form an important part of the clinical record. Each HCP is responsible for keeping up-todate, accurate, relevant and complete progress notes for people on their caseload. Progress notes should
be entered into RiO following contact with the person and the ‘validate this note’ box ticked when completed
(this is the equivalent of signing an entry in the paper notes). The following table provides guidance on
completing progress notes:
Item
Guidance
Date
Select the date and time the person was seen so that the progress
notes appear in chronological order.
Content
The entry should be concise and an accurate reflection of the contact
with the person using our services - see below.
When adding a new note it is essential to select the problem/need type
(Care Plan) to which it relates. This will allow the filtering of notes
according to the Care Plan problem/need type.
Problem/Need types
Timeliness
Progress notes must be updated as soon as possible following contact
with the person and, in line with Trust standards for entries:
http://nww.devonpartnership.nhs.uk/default.asp?a=8428&m=0
• In-patient/acute services: all entries to be complete by handover of
shift/end of duty or immediately where a significant/risk event is
identified.
• Community services: all entries to be complete within one working
day of community or outpatient contact or immediately where a
significant/risk event is identified.
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Item
Guidance
Risk Events
Progress note entries relating to risk events must be added to Risk
History and the appropriate risk(s) selected in order for the information
to be pulled through to the Latest Risk Information on front of the case
record. If a progress note is marked as relating to risk, the risk
assessment and Care Plan should be reviewed to ensure they are up
to date and changes made as appropriate. Progress notes linked to risk
are automatically added to the significant events screen.
Progress note entries can be marked as a significant event by ‘ticking’
the relevant box, which allows them to be easily located and viewed.
Significant Events
Clinicians would tick ‘this is a significant event’ if the course of
treatment is altered due to a life event e.g. Started a job, completed a
course, etc.
From the significant events list view it is possible to view the text of the
progress note in question.
Other information e.g.
reports/correspondence
from outside agencies
Must be scanned and shredded and reference made to the uploaded
document in the RiO progress notes. The reference must include:
• Title (what is it? Filename in the RiO document store)
• Author (who wrote it?)
Psychotherapy process
notes
3rd party information
Validation
• Date (when it was received?)
See the Guidance on Recording Information on RiO which is available
on the RiO pages of the Intranet and the section on Secure envelopes
in Section A of the SOPs
Progress note entries containing 3rd party information, must be marked
as such by ‘ticking’ the relevant box at the foot of the progress notes
screen. 3rd Party refers to anyone not directly involved in the provision
of care through services such as DPT, DCC etc. It would include
carers, friends and family and other service users. 3rd Party information
might include reference to information provided by a 3rd Party, or about
a 3rd Party e.g. observations of interactions between the person using
our services and another person.
Validation
All staff except students / trainee Psychologists will be able to validate
their own progress notes. This is a Trust decision and effectively does
away with the practice of countersigning unqualified staff’s notes.
However the quality of notes should be looked at as part of the
supervision process with support provided to those who need to
improve practice in this area. All notes should be validated as soon
as possible, ideally at the time of entry. See below.
In order to validate student notes, the supervisor will need to have the
relevant access set up in RiO by the Application Support Team.
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Item
Guidance
Timescales for validation
It is the responsibility of the HCP for the person using our services to
ensure that all entries are validated as soon as possible after their entry
onto RiO. The expected timescales for validation are:
• Entries made by the HCP – must be validated as soon as the entry is
completed.
• Entries made on behalf of the HCP:

Urgent: - validate within 24 hours, or sooner.

Routine/non-urgent – validate within 5 working days.
2. Standards of record keeping
These are essentially the same as for paper records – see the Records Management Policy on the intranet.
However there are some differences, for example the guidance on date/time recording for progress notes.
In Rio this can be the date/time of the contact because the system also automatically records the date/time
of the entry.
http://nww.devonpartnership.nhs.uk/default.asp?a=8428&m=0
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:




Situation - What is happening, current issues
Background - What might have lead up to the current situation
Assessment - Formulation of what is going on, including any thoughts about diagnosis
Recommendations/Decisions – What should/will be done including investigations.
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 in capitals. This will aid
identification of those decisions. Full assessment of capacity should be recorded in line with the guidance
on the MCA, see Section F1 in this document. For policy guidance see M07 Mental Capacity Act Policy.
Linking the progress note to the care plan will aid tracking and evaluation of the effectiveness of the
interventions set out within the care plan.
3. Entries by administrators/ secretaries on behalf of clinicians
Administrators / secretaries can only record information on progress notes and assessments/forms on
behalf of a clinician if the information is dictated or written and the administrator has the associated access
rights. The name in the ‘Originator’ box at the top of the progress notes must be changed to that of the
originating clinician. This prevents the notes being validated by anyone other than the originating clinician.
The entry must:
• Include the name and designation of the dictating clinician
• Only include what has been dictated or written by the clinician
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• Be checked and amended if required prior to being validated by the originating/ dictating clinician.
In exceptional circumstances, e.g. an incident or near miss; someone disclosing information over the
telephone or in a reception area, and as agreed with local operational practice, administrators / secretaries
can make their own progress note entries for factual information they have received directly and to record
their own actions. All information entered must also be communicated to the relevant clinician.
Telephone/verbal messages concerning the person using our services should be relayed to the HCP
involved, via agreed local procedure, and the HCP enters the contact on RiO.
4. Emails
The clinical content of emails which previously would have been printed and placed in the notes should be
copied and pasted to the progress notes and headed as taken from an email and the author identified. Care
must be taken not to include non-clinical information that is not pertinent to the clinical record. The author of
the email should be made aware of this use of their email.
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J. Care Planning/ Recovery Planning & CPA /Review
1. Recovery Coordination.
Information about the Recovery Approach and Recovery Co-ordination can be found on the DPT Intranet.
http://nww.devonpartnership.nhs.uk/default.asp?a=10301&m=0
Further information about what should be recorded at reviews and about Care Planning in RiO can be found
on the Intranet RiO pages under each team/service. Link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11058&m=0
Where Care Plans relate to care requiring authorisation by IPP, the Recovery Coordinator should create
these in the usual way and against each intervention set ‘Authorised by’ to ‘Panel – pending’. Once panel
approval has been granted, the IPP team should edit the intervention and change ‘Authorised by’ to ‘Panel
– agreed’. This will only be an indication of authorisation if done by a member of the IPP team. The IPP
team should also enter a brief progress note regarding the decision. This process does not remove the
requirement to communicate applications/decisions in the usual way.
For All Non CPA Clients
Care Plan
Record problems/needs and interventions
The identified Recovery Co-ordinator should use the Care
Plan Library to pull up the problem/need and intervention for
the appropriate level of recovery coordination.
All other problems on the Care Plan should start with the name
of the team to help identification of Care Plans in multiworker
situations.
Section 117
Recovery Coordination Level library
Care Plan
Care Plans should be personal and relate to assessed need
and where possible be developed in collaboration with the
person involved.
See Section 1.3 below. The Section 117 Aftercare plan is
recorded in a Library Care Plan edited and personalised for
the individual. This pulls through to the printable Care Plan
which is sent to both the Social Care panel and the MHA
Office.
The start date should be entered on the recovery co-ordination
Care Plan. When there is a change to the recovery level the
end date should be entered on the existing Care Plan which
should then be closed along with the interventions associated
with it. The new recovery level Care Plan should be selected
from the Care Plan library and a start date entered.
Care Plan contact
Care Plan distribution
Record office and out of hours contacts
Record dates that Care Plan has been distributed to involved
parties. If a copy of the Care Plan is not given to the person
using our services, record the reason why
Crisis Relapse and Contingency
Planning
Record the crisis plan
Record relapse indicators/warning signs
Record contingency plans
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The process for accessing services after discharge should be
identified within this form and a copy given to the person and if
appropriate, their carer/ GP
Allocate a Care Co-ordinator
Only used for CPA
Schedule CPA Review
Schedule a Non-CPA Review
Only used for CPA
Review appointments should be booked in the HCP diary with
review as the appointment type and also as the activity.
Found in Outcome Measures. The clustering assessment
should be completed at each review point. Further guidance is
in the Outcome Measures/Clustering Section.
Employment and accommodation information should be
updated by creating a new form at least yearly.
Clustering Assessment & Clustering
Allocation
Social Inclusion
Outcome the CPA Review
Only used for CPA
Outcome the Non-CPA Review
The review appointment should be outcomed in the normal
way ensuring the Review was added as the activity before
outcoming.
The content of the review should be recorded in the Progress
Notes and should cover the following (as relevant):
o clear statements of shared goals and formulation
o who was present at the review and their
relationship to the client
o what has been helpful
o what has not been helpful
o consideration of carer’s needs
o outcome of interventions
o outcome of review.
o Section 117 care plan (if applicable)
o Social Care Contracts (Adult Services only)
Complete the Section 117 review form on RiO. This pulls
through to the printable care plan which should be sent or
emailed to the MHA Office and the Social Care Panel
Section 117 Review
For Clients on CPA
Care Plan
Record problems/needs and interventions.
Where Section 117 applies, this Care Plan should be pulled
through from the Care Plan library and edited accordingly.
Each item on the Problem/needs list should have at least one
intervention related to it. The person responsible must e
identified in each case.
Problems on the Care Plan should start with the name of the
team to help identification of Care Plans in multiworker
situations.
Section 117
Care Plans should be personal and relate to assessed need
and where possible be developed in collaboration with the
person involved.
See Section 1.3 below. The Section 117 Aftercare plan is
recorded in a Library Care Plan edited and personalised for the
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individual. This pulls through to the printable Care Plan which
is sent to both the Social Care panel and the MHA Office.
Care Plan contact
Record office and out of hours contacts.
Care Plan distribution
Record dates that Care Plan has been distributed to involved
parties. If a copy of the Care Plan is not given to the person
using our services, record the reason why
Crisis Relapse and Contingency
Planning
Record the crisis plan
Record relapse indicators/warning signs
Record contingency plans.
Allocate a Care Co-ordinator
Allocate a care co-ordinator
Choose CPA level ‘Enhanced’
Schedule CPA Review
Invite participants
Clustering Assessment & Clustering
Allocation
Found in Outcome Measures. The clustering assessment
should be completed at each review point. Further guidance is
in the Outcome Measures/Clustering Section.
Employment and accommodation information should be
updated by creating a new form at least yearly.
Social Inclusion
Outcome the CPA Review
Validate the CPA Review
Record outcomes from the CPA review;
 Review unmet needs
 Person using our services view
 Carer view (Note: this does not appear on the printable
Care Plan like the other sections of this form)
 What worked well
 What did not work well
 Other notes.
Other notes should include the involvement of family/carer
and their expectations/comments.
Review type:
 Referral review: for 1st review (referral source should
match what was recorded when the referral was added to
RiO)
 Discharge review: for review prior to discharge from the
service
 Other review: for all others
HoNOS and social inclusion information can be pulled through
to the CPA outcome screen providing they have been
completed in RiO prior to outcoming the review.
This must be ticked to validate the review
Book future CPA Review
Schedule the next CPA review to allow this to pull through to
the printable Care Plan.
Section 117 Reviews
Complete the Section 117 review form on RiO. This pulls
through to the printable care plan which should be sent or
emailed to the MHA Office and the Social Care Panel.
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1.1 Signing of Care Plans
The Care Plan should be printed and presented to the person for whom it was developed and discussed.
The outcome of the agreement should, where possible, be the signing of the Care Plan by the individual.
This should then be recorded and the signed Care Plan scanned and saved to the record. The Care Plan
distribution form must be completed as well to indicate that the Care Plan has been shared with the person.
1.2 Care Plan Library
RiO has a number of pre-written Care Plans available in the Care Plan library. These are generally for
specific purposes such as identifying the level of Recovery Co-ordination, recording Section 17 Leave, etc.
Most of these will require editing in order to make them relevant to the person whose care they relate to.
Decisions regarding the content of the Care Plan library are made by the RiO Clinical Governance
Committee.
1.3 Section 117 Aftercare recording
Section 117 Aftercare is recorded in Care Planning in RiO using a Library Care Plan. The
Recovery Co-ordinator should select the relevant intervention headings to save to the record. This
Care Plan needs to be edited to suit the person’s situation and details of their needs in each of the
relevant areas must be added along with details of the interventions planned, the anticipated
outcomes and the person responsible. ‘Authorised by’ should be set to ‘Section 117’. When
reviewing Section 117 Aftercare (either within CPA or separately) the Section 117 Review form in
RiO should be used. This pulls through to the printable Care Plan. The printable Care Plan should
be sent (mail or email) to the MHA Office and the Social Care Panel at the beginning of Section
117 Aftercare and at each review point.
1.4 Recording Key Safe Details within RiO
This information MUST NOT be recorded in the address field in RiO as this makes it accessible via the
national spine. Where it has been agreed that staff will access a person’s home using a key safe, this
should be recorded in a Care Plan. The reason for the use of the key safe should be indicated in the
problem /need box along with the names of staff authorised to use this and the key safe details in the
intervention. The person’s consent to this should be indicated in the text of the Care Plan and where
possible by them signing their whole Care Plan including this aspect and this signed document being
scanned and uploaded to RiO.
Thought will need to be given to the distribution of the Care Plan when it contains this kind of information
and where possible the person using our services should decide who should receive this. The printable
Care Plan can be edited before printing/ sending to other parties to remove this information if necessary for
security reasons.
2. MDT Review Meetings & Supervision
When a team is reviewing a person’s record or progress, a projector will be available to allow all attendees
to view and update the patient record during the meeting.
Supervision should include the review of records such as progress notes and assessments in RiO to
support best clinical practise and identify any issues arising including training needs.
Clinical information/ outcomes should be recorded in the progress notes.
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3. MAPPA
Guidance regarding MAPPA can be found on the DPT Intranet under Safe Services or by following
the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=11522&m=0
There will also be an e-learning course available via the Online Course Programme.
The following guidance is taken from the draft Memorandum of Understanding for Devon & Cornwall
MAPPA:
Devon Partnership NHS Trust has a statutory duty for the responsibility of identifying MAPPA eligible
offenders. Therefore Devon Partnership NHS Trust need to ensure that systems are in place to indentify
MAPPA nominal’s under mental health supervision or care and ensure that the data is available, ideally
through a dedicated database. Once identified a clear ‘MAPPA eligible’ indicator flag/label on internal
case management systems should be created, to alert those involved in the management of the
offender/patient.
It is part of statutory duties to provide details of MAPPA nominal’s to MAPPA co-ordinator. It is a
requirement that Devon Partnership NHS Trust notify the relevant local MAPPA Administrator with brief
details of relevant offender using the MAPPA form G. These details will be recorded and filed but it is the
responsibility of the Devon Partnership NHS Trust to review and inform the MAPPA administrator of any
changes.
It is important to remember that all MAPPA minutes are confidential and closed under the
Freedom of Information Act 2000.
All minutes/information is securely stored electronically or in paper records in accordance with the
MAPPA guidance 2009 and the Data protection Act 1998. Minutes are not to be shared with the
offender/patient or 3rd parties unless approval is sought from the Chair of the meeting as stated in
guidance.
MAPPA minutes can be stored on RIO.
MAPPA co-ordination is the responsibility of the Responsible Authority. Reference to MAPPA meetings
should be recorded in the RiO progress notes with reference to any agreed actions and risk management
plans. The Care Plan should describe any intervention planned from DPT.
Scanned documents should be uploaded as document type ‘Meeting Minutes/Notes’ and the document
details box should be used to identify the document as highly confidential and sensitive and any limitations
on access. These comments will be for guidance only as access cannot be restricted. Where minutes are
regarded as pertaining to a current legal case, guidance on their secure storage should be sought from
Information Governance Department.
The MAPPA review form should only be used to record meetings if DPT is the lead agency e.g. Level
1. Further policy guidance is currently being developed in the Trust.
3.1 MAPPA Review Form
Field
Date of Review
Mark as complete
Guidance
Date of the Review the form relates to
Tick this box to indicate that the form is
complete. This locks the form and prevents
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Date of MAPPA referral
Community Consultant
MAPPA review date
Venue
Who was present
Who was absent
Who sent apologies
Those providing input but not present
Review unmet needs
Client View
Carer View
What worked well
What did not work well
Other notes
Offender Category
MAPPA level
Agencies Involved
Comments
further editing.
Date of the original referral to MAPPA
Select from the drop down list
Not configured at present – contact AST to get a
venue added
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Full names, roles and agencies must be listed
here
Anything not covered above
Select from drop down list
Tick the boxes – the drop down lists are not in
use, record details in comments box below
Detail the agencies involved
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K. Diagnosis, Clustering & Outcome Measures
1. Diagnosis
Everyone seen in DPT should have a working diagnosis recorded in the diagnosis screen in RiO. All
inpatients should have a confirmed diagnosis prior to discharge. Guidance on developing and recording
diagnosis is available on the Best Practice & Consistency pages.
2. Clustering Assessment & Allocation
Everyone seen in DPT for assessment and beyond is required to have a Clustering assessment and a
Cluster Allocation recorded in RiO. Specific training on this process has been delivered to teams that will be
carrying this out and the process is also documented in the Mental Health Clustering Booklet, a national
document, which is available on the Intranet via the RiO pages under PbR or using the link below.
http://nww.devonpartnership.nhs.uk/default.asp?a=11502&m=0
The Clustering Assessment and the Clustering Allocation forms are found in the Outcome Measures folder
on the front of the case record and a new form should be created to record each Clustering Assessment
and Clustering Allocation carried out.
Clustering is the responsibility of the initial assessor and reviewing the cluster / re-clustering where required
is the responsibility of the Recovery Co-ordinator (in consultation with others involved in the person’s care
as appropriate). Where only one clinician is involved in the person’s care from DPT, this person is the de
facto Recovery Coordinator whatever their role or profession and they therefore hold the responsibility for
reviewing/ re-clustering as required.
Clustering Assessment Fields
Guidance
Date/Time
Date and time of the assessment or review to which the
Clustering Assessment relates
Search for and select the relevant referral
Referral/Admission
Mental Health Clustering Tool reason
HoNOS Assessment & Additional
Assessment Questions
New Referral – relating to initial assessment following initial
referral from an external source to DPT
CPA Review – relating to a CPA review
Review (Non CPA) – relating to any other reviews
Other Significant Change in Need – where this does not lead to
a review e.g. crisis situations
Other Not Elsewhere Specified – for use when clustering
existing caseloads during the implementation of this process.
Select the appropriate scores (based on the available evidence
and using the scoring guidance) from the drop down list
The Clustering assessment should be saved before clicking on the link to the Clustering Allocation form.
Clustering Allocation Fields
Guidance
Date/Time Assessment undertaken
Should be the date/time of the initial assessment/review and
should match the date/time of the Clustering Assessment
Should match the reason selected in the associated Clustering
Assessment
Search for and select the Clustering Assessment on which the
Cluster Allocation is based
Mental Health Clustering Tool reason
Associated Clustering Assessment
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Care Cluster Identification Date
Super Class
Care Cluster
Care Cluster End Date
Care Cluster End Reason
Date on which the care cluster was identified (may be different
from the assessment date)
Select from: Non Psychotic, Psychosis, Organic or Unable to
assign person to super class. This last option should only be
chosen where the person is being allocated to Cluster 0 –
Variance.
Select the identified Care Cluster from the drop down list.
Remember Cluster 9 is not currently in use.
Entered when the person is discharged from DPT or prior to
allocating to another cluster following a review/ significant
change in need.
As above. Select the appropriate reason from the drop down list.
3. Outcome Measures
There are a number of versions of HoNOS available in RiO for use as outcome measures. Where the
Clustering Assessment is in use, there is no requirement to complete other versions of HoNOS.
Where the Clustering Assessment is not in use, the following should be used:
Outcome Measures
Guidance
HoNOS – LD
To be used in LD services
HoNOS – Secure (v2)
To be used in secure services
The Trust’s form ‘How well is life working out for you?’ should also be used both initially, at regular review
points and prior to discharge. This form can be found on the Intranet in the Recovery Co-ordination section.
http://nww.devonpartnership.nhs.uk/default.asp?a=10301&m=0
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L. Mental Health Act Administration
1. Approved Mental Health Practitioners (AMHPs)
AMHPs will complete the Mental Health Outline Report (MH1 Assessment as identified in RIO) on RIO. This
form always pulls through information from the last version completed and this may need to be reviewed
and amended before new information is added. It is essential to ensure that the date of the assessment
and the referral it is linked to are correct on this form.
Completing the MH1 Form:
Most of fields are text boxes and the requested details should be completed or not applicable should be
indicated.
Field
Guidance
Date of Assessment
This must be set to the date the MHA assessment was carried out
Referral
Search for the AMHP referral – ensure that this form is linked to the correct
referral.
Nearest Relative name
If these details have previously been entered on RiO they will show here. There
(MHA)
is a link to update this information.
Outcome of the
Select from the drop down list
assessment
Time of Assessment
The start time of the assessment
Time Spent
The length of time spent on the assessment
Completed by
Search for the name of the person completing the form
Completed date
This indicates that the form is complete.
Section papers will normally be scanned onto the system by the Mental Health Act Administrators. Where
there is likely to be a delay to this (weekends etc), paper copies of the relevant forms will be held on the
ward until the system is updated and these will then be shredded.
2. Recording Mental Health Act Information on RiO
RiO provides a Mental Health Act Administration function – which will only be accessed by designated
Mental Health Act Administrators or nominated deputies. It is the MHA Office's responsibility to ensure that
paperwork has been completed correctly and that the person's rights have been upheld. This is the reason
for paperwork relating to MHA being sent to the MHA Office before being scanned onto the system.
Paperwork that needs to be processed in this way includes CTOs, Section 62 (and 64G), T2/T3, Recent
Discharge Notice. Reports for Tribunals should also be sent to the MHA Office (preferably electronically)
and they will circulate them and upload them. They will be saved as document type Report/Assessment in
RiO. The MHA document type should only be used by the MHA Office and only for the legal forms. The
naming convention outlined in the SOPs will be adhered to e.g. 'Cedars Tribunal Report'.
Copies of the relevant paperwork may be held temporarily e.g. on the ward following an admission under
Section, but these copies should be shredded once the originals are on RiO and the MHA information has
been updated.
Mental Health Act Legal files will be held at the Mental Health Act Office as at present.
3. Access to RiO for external parties relating to people who use our services
and who are subject to the Mental Health Act
There are 3 groups of external parties who have the right of access to RiO. The following table gives brief
guidance on how to deal with requests to access RiO information relating to clients subject to the Mental
Health Act. This process is under review and new guidance will be issued if required.
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Access Request From
Guidance
Mental Health Tribunal
Medical Member
(Section 12 Doctor)
On arrival in an inpatient service – must be asked to show identification
and be directed to the Ward Manager or the relevant person’s named
nurse.
On arrival in a community service – must be asked to show
identification and be directed to the relevant person’s Care Coordinator,
lead HCP or Consultant.
The doctor should be given supervised access to RiO (i.e. the person
supervising must use their Smartcard and log into RiO) and the person
supervising must record a progress note on RiO stating who is
accessing the information and the time/ date.
If it is not possible to give supervised access, the required information
should be printed off and a progress note recorded on RiO stating who
has requested the information and the date.
Access Request From
Guidance
Second Opinion
Appointed Doctor
(SOAD) – appointment
by the Care Quality
Commission
Solicitor appointed
Doctor (on behalf of
person using our
services)
As above.
As above but, in addition to identification, the Doctor must be asked to
provide a letter of authorisation.
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M. RiO Documentation
The following guidance should be used regarding the selection of a document type when saving a
document to RiO:
Document Type
Examples
Advance directives
Only specific advance directive documents
Care Plans
Consent to share information
Copies of WRAP Plans
Care Plans from non- RiO services
Signed non CPA Care Plans
Copies of the signed forms
Deprivation of Liberty Safeguards
Documents relating specifically to this
Discharge summaries
Summaries produced by any service on discharge of a
referral or admission whether in letter or report form
Genograms only
Genogram
Images - Charts
Medicine charts
Other physical monitoring charts not covered in the Physical
monitoring form in RiO
Images - Others
Images – Photographs
Images – X-rays/Scans
X-ray/ scans
Investigation results
Blood tests, ECG etc.
Letters – Clinic
Clinic appointment letters
Letters – other
Letters – Referrals
Meeting Minutes/Notes
Mental Capacity Act
MHA Documents
Printable CPA Reviews
Reports/ Assessments
Referrals in to DPT from external sources, letters referring out
of DPT
MAPPA / MARAC Minutes, Safeguarding children minutes
MCA Assessment forms which must also be referenced in the
MCA forms in the case record (See MCA guidance in Section
F)
Only to be used by MHA Office. Tribunal reports, Section
117 forms and CTO reports should be submitted to the MHA
Office and they will upload them here.
The exception to this is where a paper Section 17 form is
provided out of hours and this can be uploaded by ward staff
– this should be a rare occurrence.
Signed copies of CPA review forms (Printable Care Plan)
Reports and assessments including those in letter format e.g.
to a GP or other referrer. This should be used rather than
Letters – Clinic/Other where the content of the letter could be
described as a report or assessment.
Uploaded reports from external sources e.g. primary health
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care.
Risk
Safeguarding vulnerable adults
Social Care Commissioning
Risk assessment/ information received in document form
from external sources
Safeguarding Adult meeting minutes, correspondence with
Safeguarding Team DCC
Correspondence specifically relating to this including panel
reports
1. Editable Letters
An editable letter is standard document that contains information about the individual drawn from RiO. Once
selected it is opened in MS Word and can be further edited and then printed.
When an editable letter is created in RiO, it will need to be ‘uploaded’ back into the RiO document store in
the patient record once the final version has been printed. The following naming conventions should be
used:
Item
Guidance
Example
Name of the signatory for or author of the document – if left
blank this defaults to the name on the Smartcard of the
person currently logged in.
Team (using abbreviations detailed below- no space in team
name/location)
Type (e.g. clinic letter, DNA letter, Care Plan, etc)
Other relevant detail
The maximum number of characters including spaces is
40.
Date that the letter was created
Smith, John –
RILNDevTaw
File
Author
Document
Title
Document
Date
Document
Type
MWATorb DNA
Letter1 or
SDevPsy Complex
Assessment Report
Select the appropriate type (see table at the beginning of this
section)
Description
This is free text field – information that helps indicate the
content of the document and details any restrictions on
access for example with Safeguarding minutes/ MAPPA
minutes The fact that a document contains 3rd Party
information should also be recorded here.
Viewing restricted to
those present at
safeguarding
meeting on 26 04
2010
Or
Safeguarding
referral form –
contains 3rd Party
Information
Or
Appointment
confirmation letter
Initially the following editable letters will be available on RiO:
Name of Letter on RiO
1. Appt Cancelled
2. 1st Contact Letter
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3. Confirmation of Appt arranged by phone
4. DNA
5. Waiting List following initial assessment
6. Review Appt
7. Transition to another service
8. Set Appointment time letter
9. How are you
10. Transition from another service
11. Further info request
12. Discharge – no contact
13. Discharge agreed
2. Team Abbreviations for use in document titles
Team Type/ Name
Additional Support Team (Learning Disability)
Approved Mental Health Professional Team
Arts Therapies Service
Assertive Outreach Team
Autistic Spectrum Condition Service
Clothing Works
Community Neuropsychology
Crisis Resolution & Home Treatment Service
Eating Disorder Service
Emergency Duty Team
Exeter Occupational Therapy
Forensic Services
Gender Identity & Sexual Therapy
Health & Inpatient Neuropsychology
Medical Staffing Learning Disability
Mental Wellbeing & Access
New Leaf
North Devon Link Service
Older People’s Mental Health Team
Older People’s Psychology
Perinatal Service
Personality Disorder Service
Psychiatric Liaison Service
Psychotherapy Service
Recovery & Independent Living
Rehab & Recovery Team
RIL Homeless Service
Russell Clinic
South Devon Psychology
Specialist Team In Early Psychosis
Workways
Approved Abbreviation
ASTLD
AMHP
ArTS
AOT
ASCS
CWorks
CNeuroPsy
CRHT
EDS
EDT
ExeterOT
FOR
Gender
INeuroPsy
LDMedic
MWA
NewLeaf
NDLink
OPMH
OPPsy
PNatal
PDS
Liaison
Ptherapy
RIL
REHABR
RILHS
Russell
SDPsy
STEP
WWays
Urgent &Inpatient Care
UIC
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Abbotsvale
Avon
Beech Unit
Brunel Lodge (now Beech Unit)
Cabot
Chichester House
Coombehaven
Delderfield
Drake
Exeter Additional Support Unit (LD)
Haldon
Haytor
Haytor & Oak High Dependency Unit
Knightshayes
Meadow View (Formerly David Barlow)
Melrose
Moorland View
Oak
Ocean View
Owen House
Raleigh
Russell Clinic
St John’s Court
The Bungalow
UICAbbot
ForAvon
UICBeech
UICBrunel
FORCabot
FORCH
UICCoombe
UICDeld
FORDrake
ASULD
Haldon
UICHaytor
HaytorHDU
KnightLD
UICMead
UICMelrose
UICMoor
UICOak
UICOcean
FOROH
FORRaleigh
UICRussell
UICStJC
UICBung
Location
East Devon Exmouth
East Devon Honiton
Exeter
Exeter, East & Mid Devon
Mid Devon
North Devon
Paignton
South &West Devon
South Devon
South Hams
Tawside
Teignbridge
Torbay
Torridge
Totnes
West Devon
Abbreviation
EDevEx
EDevHo
Exeter
EEM
MDev
NDev
Pgton
SWDev
SDev
SHam
Taw
Teign
Torb
Torr
Totn
WDev
Examples of how these might be combined are:
RILEDevEx for Recovery &Independent Living, East Devon, Exmouth
AMHPMDev for Approved Mental Health Professional Team, Mid Devon
MWANDevTorr for Mental Wellbeing & Access, North Devon, Torridge.
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3. Uploading documents
Any paperwork including letters and documents relating to the person using the service that would normally
be stored in paper file should be scanned and uploaded into the person’s clinical record on RiO. Once RiO
has been checked to verify the document has been uploaded successfully and remains readable the
original should be shredded. The scanning / verification / shredding process should be undertaken by the
same person responsible for uploading the document.
Any document that needs to be uploaded to the clinical document store which contains 3rd party information
must make reference to this fact. To do this you must indicate in the description box that the document as
containing 3rd party information.
Editable letters should be uploaded electronically back to the persons record once it has been printed.
The clinical content of emails which previously would have been printed and placed in the notes should be
copied and pasted to the progress notes instead and headed as taken from an email and the author
identified. Care must be taken not to include non clinical information that is not pertinent to the clinical
record.
For documents with a high level of confidentiality e.g. MAPPA or Safeguarding minutes, the comment in the
description should indicate that the document should only be viewed by those present at the meeting and
give the date.
4. Document Templates via Intranet/ Shared Drives
A range of document templates and rating scales will be developed over time and accessible through the
intranet. Some teams/ services have retained templates for communication outside DPT which are available
through shared drives. It is essential that documents created in this way are deleted from the drive once
they have been uploaded to RiO.
5. Scanning policy
Each Team will have access to a scanner which will be attached to a specific computer. Scanning guidance
can be found at:
http://nww.devonpartnership.nhs.uk/default.asp?a=11070&m=0
Documents including, rating scales and letters that were normally filed in former paper notes should be
scanned into RiO. A4 Scanners are available in all units with A3 scanners available in inpatient units for the
scanning of medicine charts.
6. Shredding policy
After scanning into RiO, the scanned documents should be verified. Following verification documents
should be disposed of through shredding either locally or through confidential waste schemes.
7. Document Naming Conventions
The following describes the naming scheme that should be applied to documents scanned into RiO to aid
retrieval.
Item
Guidance
File
This will be the existing document name that you
are searching for. If it is a scanned document it will
be the name allocated to that document during the
scanning process. This name does not appear on
Example
Standard Operating Procedures V5
14.10.2011
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Printed versions of this document may be out of date – please check the intranet to ensure you have the current guidance.
RiO Standard Operating Procedures
the case record.
Author
Document
Title
Name of the person who originated the document.
If this is a scanned, uploaded document and the
author is not known or evident then the source of
the document should be used e.g. Safeguarding
Team / IPP
Team (as it appears on RiO)
Type (e.g. clinic letter, DNA letter, Care Plan, etc)
Document
Date
Document
Type
Date that the letter/ document was created
Description
This is free text field – information that helps
indicate the content of the document and details
any restrictions on access for example with
Safeguarding minutes/ MAPPA minutes. The fact
that a document contains 3rd Party information
should also be recorded here.
Smith, John –RILNDevTaw
MWA TorbDNA Letter or
SDevPsy complex assessment
report
Select the appropriate one (see guidance at the
beginning of this section)
Viewing restricted to those
present at safeguarding
meeting on 26 04 2010
Or
Referral letter from GP –
contains 3rd Party Information
Or
WRAP plan 22 07 2010 etc.
8. Printing Clinical Information from RiO
There is a risk that information printed from RiO will not have the patient demographic information printed
on sheets after the first page for reports that were person specific. This could contribute to printed
information after page 1 being interpreted as belonging to a different person than the one that was intended.
Similarly, an HCP may refuse to utilise printed clinical information if it does not contain the mandatory
identification details.
It is also possible that reports will not contain page numbering or an ‘end of document’ statement. This
could compromise an HCP’s ability to detect that a report has completed printing and therefore contains the
expected clinical information.
Staff should refrain from printing clinical information unless absolutely necessary and instead use
information direct from the screen. Where printed material pertains to a specific person staff should check
the identity of the printed material against the on-screen information and mark the sheet(s) accordingly.
Where printing is necessary, users should compare the printed material with the on-screen information to
ensure that the printing has completed correctly.
If it is necessary to print progress notes from the record (e.g. for a subject access request), it is preferable to
do so from the Patient Data View of the progress notes as these are more printer friendly. NOTE: RiO will
only print 50 pages at a time so you need to select a timeframe for the progress notes in order to print in
batches. For guidance on processing Subject Access requests please see the Governance Section of the
Policy & Procedures section of the Intranet or use the link below:
http://nww.devonpartnership.nhs.uk/default.asp?a=8428&m=0
Standard Operating Procedures V5
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