standard operational procedure 12b (sop 12b) filing cypf

Filing – Specialist Mental Health of 23 Version 1.2 May 2019

Standard Operational Procedure 12b (SOP 12b)

Filing – CYPF Specialist Mental Health Services Health Record Folder

Why we have a procedure?

It is a requirement of the Trust all documentation regarding the treatment and care of our service users is accurately filed within the Trust’s identified health record folder. Adequate records must be filed to account fully and transparently for all actions and decisions, in particular:

To protect legal and other rights of patients, staff, and others affected by those action.

To facilitate audit or examination.

To provide credible and authoritative evidence.

Filed in a designated secure storage area. The purpose of this procedure is to enable all staff to ascertain where various clinical information recording documents are to be filed within health record folders used throughout the CYPF Specialist Mental Health Group. A paper copy of the new dividers will be placed at the front of each new file to refer to as a guide for CYPS Specialist Mental Health cases.

What overarching policy the procedure links to?

This Standard Operational Procedure is linked to the Health Records Policy and the Health Records Folder – Filing SOP which is Trust wide.

Which services of the trust does this apply to? Where is it in operation?

Division Inpatients Community Locations

Mental Health Services

Learning Disabilities Services

Children and Young People Services all

Who does the procedure apply to?

It is the responsibility of ALL CYPF Specialist Mental Health Services staff to maintain the record folder in good order.


This procedure applies to all staffs who contribute to the filing of a health record, inc: All Administration and Clerical staff All Clinical and Nursing staff All Medical staff

When should the procedure be applied?

All outstanding filing should be filed effectively and efficiently on a daily basis to ensure health records contain up to date and relevant information.

How to carry out this procedure

Using the current standard Health Records / Casenotes with standard dividers, the following information should be recorded in each section and subsection as listed below: Clip 1

Alerts o Safeguarding Children Concern o Safeguarding Adult Concern o Risk (e.g. Violence and Aggression) should be used to also record

Lone Working concerns o Allergies and Sensitivities o Additional Needs o Infection Control o Risks should be used to record any risks including Lone Working

concerns

Please note: Advance Decisions / Statements, Anaesthetic Reactions and Medication Cautions and Decision Not to Resuscitate should not be included or used by CYPF Specialist Mental Health Services

Demographics o Patient ID Labels o Change of Details Form o Contact Sheet for Family / Carers o Contact Sheet for Professionals Involved o Approved Abbreviation List o Signature List o Appointments and Attendance Information to list all

DNAs/Cancellations/Attendances Please note: Admission Booklets, Admission Sheet, Patients Property Form and Patients Disclaimer Form should not be included or used by CYPF Specialist Mental Health Services

Multi-professional / Multidisciplinary Notes


o Initial Needs Assessment o Continuation Sheets o Signature List

Please note: History Sheets, Contact Sheets and Care Records Booklets should not be included or used by CYPF Specialist Mental Health Services

Assessments / Risk Assessments o Steve Morgan Risk Assessment Tool o Management Plan o Developmental Behaviour Checklist o Sheffield Learning Disability Outcome Measure (SLDOM) o Continence Assessment o Incident Reports o Multi-Professional Assessments o ADHD Self-Report Scale (ASRS) Checklist o Psychometric Tests o Body Mass Index (BMI) o Body Map Chart o HONOSca o Clinical Care Pathways

Please note: Screening Assessment, Common Assessment Tool (CAT), Threshold Assessment Grid (TAG), Single Assessment Process (SAP), Risk Management Plans, Waterlow Risk Assessment, Resuscitation Decision, Care Pathway Allocation Form, Clinical Outcomes in Routine Evaluation (CORE), Infection Control Screening Tool, Manual Handling Screening Tool, Search Record Form and Venous Thrombosis Evaluation should not be included or completed by CYPF Specialist Mental Health Services

Care Plans / Reviews / Crisis Plans o CPA o Care Plans – Person Centered / Recovery Focused o Crisis Plan o Contingency Plan o Reviews o Timetable

Please note: Care Packages (AC8 / AC9), Care Management, CCVU section, Community Care Contracts, Nursing Intervention Pathway, ECT Nursing Care Plan, Recovery Plans / Recovery STAR and Restraint Form should not be included or used by CYPF Specialist Mental Health Services Clip 2

Correspondence o Referral Letters o Discharge Letters o G.P Letters o Clinic Letters


o Letters to Patients o Appointment Letters o DNA Letters o General Correspondence – Incoming / Outgoing o DVLA Requests and Reports o Care Conference Report / Minutes o Emails

Please note: DSS Requests and Reports, DLA Requests and Reports and Department of Work and Pensions Requests and Reports should not be included or used by CYPF Specialist Mental Health Services

Investigations (Diagnostics and Laboratory Tests) o Mount Sheets (which should have lab reports attached to them when

provided) o Other Investigation Reports o Physical Examinations o Charts (Temperature / Blood Pressure / Fluid Balance / Weight /

Diabetic / Sleep / Food / BMI) o Bloods o EEG Reports o ECG Reports o Mini Mental State Examination (MMSE) o Bristol Activities of Daily Living Scale (BADLS) replaced by Care Givers

Questionnaire o Autism Diagnostic Observation Schedule (ADOS) o CONNERS (Rating scale / SEDQ / School Reports) o ECG/EEG/ECT Tracings o Photographs

Please note: Addenbrookes Cognitive Examination (ACE) should not be included or used by CYPF Specialist Mental Health Services

Treatment o Prescription Cards and Forms o Consent Forms o Discharge Checklist o OPD Prescription Forms o Discharge Prescription Records (TTOI’s) o Refusal to Accept Medical Advice o Prescribed Continence Products

Please note: Depot Injection Records, ECT Treatment Records, Contract for Alcohol / Substance Detoxification should not be included or used by CYPF Specialist Mental Health Services

Mental Health Act / Mental Capacity o Correspondence o Copy Section Papers o Patient’s Rights Forms


o Consent to Treatment o Any Mental Health Act Papers, including reports concerning Mental

Health Act o Social Circumstance Report o 136 Reports o Other Court Reports

Please note: Section 17 Leave Forms, Hospital Managers Hearing / Outcomes, MHA Tribunal Hearing / Outcomes and AWOL (Absent Without Leave) Forms should not be included or used by CYPF Specialist Mental Health Services

Mental Capacity o Capacity and Consent o Best Interest Decision o DOLS (Deprivation of Liberty Safeguards)

Third Party Information / External Reports o Childcare Case Conference Reports o Child Protection investigations o Multi-Agency Public Protection Arrangements (MAPPA) Related

Material o School Reports o Housing Authority Reports o Anti-Social Behaviour Order Reports from the Police o Reports from External Sources o Electronic Marker Notification Forms o Family Statements, Reports o Vulnerable Adult Protection (VAP) Forms / Investigations o Outside Medical Notes (Copies of Records from Other Organisations) o Medical Reports for Solicitors and Insurance Purposes and Courts o Local Authority Reports o Education and Health Care Plans

Please note: Observations Records Section should not be used by CYPF Specialist Mental Health Services CYPF Specialist Mental Health Good Practice Filing Guidance

1. There must be NO loose paper of any description within the record folder as

documentation must be filed on a daily basis filing of documents into patient record folders should be done on a daily basis.

2 All documentation must be filed on the clip, in the appropriate section, in date order, with the most recent document at the back. (appendix 1).

3 Volumes of health records need to be of a manageable size (approximately 2

inches/5 cm.) in width. A new volume of the record should be created when records exceed this recommendation.


Information that would incur a risk if it was retained in the old volume of the record may be transferred to the new volume but must be traceable, with each document transferred being noted on the ‘Transfer of Information’ form. (appendix 2).

4 All sections of the Front Cover AND all sections of the Patient Alert must be completed.

5 All investigation reports must be signed by medical staff before filing.

6 No paperwork must be torn out and/or removed from the record folder.

7 Every user must ensure that all the filing is complete before the record folder

leaves the ward or department.

8. No plastic pockets to be used in record folders. No staples to the front/back of file or on dividers. No post-it notes to be used.

9. Secure envelopes must be used for any documentation that cannot be filed on the clip, e.g. ECG tracings, photographs, drawings.

10. The preferred system for filing health records is by Oasis.

11. All staff should take care to keep the shelves and the records tidy, upright and free from misfiles.

12. Where patients have several volumes of record folders, they should be filed

with the most recent volume at the front with other volumes running in order behind in descending order (e.g. vol:3, vol:2, vol:1)

13. When a record is removed from their current location to a new location it must

be appropriately tracked by the use of a tracer card or entered on to the electronic case note tracking module which operated through E-HR.

Where do I go for further advice or information?

For further advice or information: Service Manager CYPF Specialist Mental Health Services Records Services Manager (Delta) Health Records Manager (Delta) Health Records Manager (Penn) Assistant Health Records Manager (Delta/Penn) Health Records Health Records Delta House Penn Hospital Greets Green Road Penn Road West Bromwich Wolverhampton B70 9 PL WV4 5HN


DDI: 0121 612 8146 DDI: 01902 445965 Training Understanding of the Oasis numerical filing system Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Refer to overarching policy: Health Records Policy and Health and Social Care Records Filing Policy. Data Protection Act and Freedom of Information Act Refer to overarching policy: Health Records Policy and Health and Social Care Records Filing Policy.


Health Record Section

What should be recorded or filed here

CLIP 1

Alerts

Safeguarding Children Concern

Safeguarding Adult Concern

Risk (e.g. Violence and Aggression) should be used to also record Lone Working concerns

Allergies and Sensitivities

Additional Needs

Infection Control

Risks should be used to record any risks including Lone Working concerns

Demographics

Patient ID Labels

Change of Details Form

Contact Sheet for Family / Carers

Contact Sheet for Professionals Involved

Approved Abbreviation List

Signature List

Appointments and Attendance Information to list all DNAs/Cancellations/Attendances

Multi-professional / Multi-disciplinary clinical notes

Initial Needs Assessment

Continuation Sheets

Signature List

Assessments / Risk Assessments

Steve Morgan Risk Assessment Tool

Management Plan

Sheffield Learning Disability Outcome Measure (SLDOM)

Continence Assessment

Incident Reports

Multi-Professional Assessments

ADHD Self-Report Scale (ASRS) Checklist

Psychometric Tests

Body Mass Index (BMI)

Body Map Chart

HONOSca

Clinical Care Pathways

Care Plans / Reviews / Crisis Plans

CPA

Care Plans – Person Centered / Recovery Focused

Crisis Plan


Contingency Plan

Reviews

Timetable

CLIP 2

Correspondence

Referral Letters

Discharge Letters

G.P Letters

Clinic Letters

Letters to Patients

Appointment Letters

DNA Letters

General Correspondence – Incoming / Outgoing

DVLA Requests and Reports

Care Conference Report / Minutes

Emails

Investigations (Diagnostic and laboratory tests)

Mount Sheets (which should have lab reports attached to them when provided)

Other Investigation Reports

Physical Examinations

Charts (Temperature / Blood Pressure / Fluid Balance / Weight / Diabetic / Sleep / Food / BMI)

Neuropsychological Assessments

Cognitive Assessments (i.e. IQ)

Bloods

EEG Reports

ECG Reports

Mini Mental State Examination (MMSE)

Bristol Activities of Daily Living Scale (BADLS) replaced by Care Givers Questionnaire

Autism Diagnostic Observation Schedule (ADOS)

CONNERS (Rating scale / SEDQ / School Reports)

ECG/EEG/ECT Tracings

Photographs

Treatment

Prescription Cards and Forms

Consent Forms

Discharge Checklist

OPD Prescription Forms

Discharge Prescription Records (TTOI’s)

Refusal to Accept Medical Advice

Prescribed Continence Products


Mental Health Act

N.B. For patients currently admitted on a Section of the Mental Health Act, the separate 7 part sets of MHA dividers (pink) should be used until the patient is discharged.

Correspondence

Copy Section Papers

Patient’s Rights Forms

Consent to Treatment

Any Mental Health Act Papers, including reports concerning Mental Health Act

Social Circumstance Report

136 Reports

Other Court Reports

Mental Capacity Capacity and Consent

Best Interest Decision

DOLS (Deprivation of Liberty Safeguards)

Third Party Information/ External Reports

Description of ‘Third Party’ information:

Any information not written by Trust staff and as such should not be shared.

The information relates to someone other than the patient.

The following are examples of information that should be stored in this section:

Childcare Case Conference Reports

Child Protection investigations

Multi-Agency Public Protection Arrangements (MAPPA) Related Material

School Reports

Housing Authority Reports

Anti-Social Behaviour Order Reports from the Police

Reports from External Sources

Electronic Marker Notification Forms

Family Statements, Reports

Vulnerable Adult Protection (VAP) Forms / Investigations

Outside Medical Notes (Copies of Records from Other Organisations)

Medical Reports for Solicitors and Insurance Purposes and Courts

Local Authority Reports

Education and Health Care Plans


Example Dividers – Where text in PURPLE indicates a change from previous system


Standard Operating Procedure Details

Review and Amendment History - to be completed by Corporate Governance

Version Date Description of Change

1.2 May 2019 Review date extended to October 2020 until the implementation of the electronic record (RiO) and its impact on current practices identified for the proper review of the SOP.

1.1 Nov 2018 SOP reviewed to include examples of drivers and remove staff names from page 6 leaving only Job Titles.

1.0 Nov 2017 New SOP for Specialist Mental Health service to support overarching Health Record Management Policy

Unique Identifier for this SOP is BCPFT-REC-SOP-01-12b

State if SOP is New or Revised Revised

Policy Category Health Record

Executive Director whose portfolio this SOP comes under

Director of Operations

Policy Lead/Author Job titles only

Project Support Officer - CYPF Specialist Mental Health Services Service Manager - CYPF Specialist Mental Health Services

Committee/Group Responsible for Approval of this SOP

Specialist Mental Health Quality and Safety Group

Month/year consultation process completed

n/a

Month/year SOP was approved May 2019

Next review due October 2020

Disclosure Status ‘B’ can be disclosed to patients and the public

standard operational procedure 12b (sop 12b) filing cypf

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