These standards apply to all Professional Groups. A member of: Association of UK University Hospitals

Transcription

1 A member of: Association of UK University Hospitals Minimum Standards for the Recording of Risk Screening, Assessment and Management Plans in Adult, Learning Disability, & Forensic Healthcare (February 2017) These standards apply to all Professional Groups. Minimum Risk Screening/Assessment recording Standards Version 2 Page 1

2 Contents Section1 - Risk Screening... 3 Section 2- How to identify if a comprehensive risk assessment is required... 5 Section 3 - Completion of Comprehensive Assessment... 6 Section 4 - Risk and Safety Management Plan... 6 Section 5 - Multi-disciplinary Risk Assessment... 7 Section 6 - Reviewing / updating the comprehensive Risk Assessment... 8 Section 7 - Risk Events... 9 Section 8 - Post CQC Immediate actions Minimum Risk Screening/Assessment recording Standards Version 2 Page 2

3 Section1 - Risk Screening All Risk recording must be completed on the Carenotes Adult-Risk Screening/Assessment Forms; these can be found in the Risk Management Tab (please see screen shots below). As you will see both of these templates are currently found under one tab (second screen shot). For Psychiatrists working as Lead Practitioner in out-patient clinics the risk assessment and safety plan should be documented and communicated in the standard GP letter which should be completed and sent out within 2 weeks. A contemporaneous entry in the Carenotes clinical notes section must be made on the day of review which should include a brief statement of risk and any major changes to the care plan. Once the GP letter has been completed and uploaded into correspondence in Carenotes, the risk management tab of the patient record should be opened and an entry made in the first field directing the reader to the labelled GP letter. If the presentation is complex or particularly risky, the Psychiatrist may choose to complete the comprehensive risk assessment in Carenotes and involve the Multi-Disciplinary Team in this process. When there are concerns regarding significant risks to self or specific others, an alert must be generated. An alert is generated via the demographics tab by clicking on the drop down box of options under the create a new tab. Please do not upload risk assessment documents on to Carenotes (other than for an onward referral to ATS if you work in Health in Mind or completed HCR 20 V3 and RSVP Forms). All adults must have a Risk Screening as a minimum (except in the context of triage and a telephone contact in which further information is required that is not considered part of a clinical assessment and/or risk related). The Risk Screening Form must be completed at the initial assessment (Face to Face or by Phone). If there is no requirement for a more comprehensive assessment of risk, the risk Screening assessment must be reviewed and updated as a minimum every 6 months or whenever there is a change in clinical presentation or circumstances. Minimum Risk Screening/Assessment recording Standards Version 2 Page 3

4 Section1 - Risk Screening (continued) Once you have clicked on the ADULTS Risk Screening / Assessment link it will open up a template. Half way down this template you will find a section that says administration. Please use the drop down box which says do you need to complete the risk screening and or the risk assessment to take you to the relevant template. Minimum Risk Screening/Assessment recording Standards Version 2 Page 4

5 Section 2- How to identify if a comprehensive risk assessment is required If any of the listed risks in the tick box table on risk screen are indicated as current you must complete a comprehensive risk assessment. If any of the listed risks identified are past, consider the context and whether a comprehensive risk assessment is required: (Aggression and violence; Any suicide risk; Severe self-neglect; History of/or current self-harm; Offending; Substance Misuse; Exploitation (by or of others); Physical Health; Disengagement; Relapse; Bullying/cyberbullying; Risk to children or adults (child or adult protection issues) vulnerability) If a comprehensive assessment is not considered to be required, you must provide a narrative on the risk screening form to support your decision of low risk/screening only. Once you have completed the risk screening you must save and confirm. Minimum Risk Screening/Assessment recording Standards Version 2 Page 5

6 Section 3 - Completion of Comprehensive Assessment If a comprehensive risk assessment is needed this should be created as a new form from the risk management tab of the patient record. When completing the assessment you must: - Involve service user/carer/family - Complete all sections, including chronology of risk events, and identify risk and protective factors level of risk - Use 5 P s model for risk formulation Once risk is assessed and recorded, please save and confirm. If it is not confirmed it will not be possible to re-plan. Section 4 - Risk and Safety Management Plan Now complete the Risk Management/Safety plan within the Adult Risk Assessment Form, (this must include a relapse prevention plan and reference a crisis plan). The Crisis and contingency plan will be found in the Personal Support Plan under the Care Planning tab of the patient record. Minimum Risk Screening/Assessment recording Standards Version 2 Page 6

7 Once completed press confirm (This plan should include or signpost a crisis and relapse prevention plan). Section 5 - Multi-disciplinary Risk Assessment This is completed where there are high and complex risks and management/care involves more than one clinician in the team or multiple agencies The Multi-disciplinary Assessment is on the same form as the Adult Risk Assessment which includes an area for you to input the names, title and role of other disciplines or agencies who have been involved in the assessment. Minimum Risk Screening/Assessment recording Standards Version 2 Page 7

8 Section 6 - Reviewing / updating the comprehensive Risk Assessment All Risk Assessments and Management plans must be reviewed as a minimum every 6 months after which they will be out of date. The risk assessment must also be reviewed / updated when: - There is any new information, or a change in the service user s presentation or circumstances which could potentially impact on risk. - Reviewing risk and risk/safety management plan at CPA reviews (e.g. 6 months). - Service user presents at A&E or requires crisis intervention activity - Admitted or discharged from hospital or custody (this includes when a patient is transferred between wards/hospitals). If on review there has been no change the risk assessment should be re-planned and a statement added confirming that there has been no change to the identified risks and safety/risk management plan. To start review or update: Open the current risk assessment under the risk management tab Click Edit at the top of the current risk assessment screen Then click Replan. Risk assessments must always be replanned rather than a new one created to prevent the loss of key historical risk information (that may not be included on a new assessment if it is not known). Once updated with all relevant changes please save and then confirm. If the risk assessment is not confirmed it means that it can not be re-planned. Minimum Risk Screening/Assessment recording Standards Version 2 Page 8

9 Section 7 - Risk Events There is a risk event section to add single events to the risk assessment forms to support the chronological collation of risk events. Alternatively, a separate All Risk Event form is available under the Risk Management tab where individual risk events can be added, these then pull though automatically into the Adults Risk Screening/Assessment form. Risk events can be added by: clicking the button in the risk assessment and by selecting this under the risk management tab as a new form which will then pull through to the Comprehensive Risk Assessment. Risk events are also viewable under the summary button at the top of the screen. Risk Events that have been recorded on Carenotes will populate automatically in the table below when the form is completed electronically. This is what the risk events look like in a risk assessment form: This is what risk events look like under the summary button at the top of the patient record Minimum Risk Screening/Assessment recording Standards Version 2 Page 9

10 Section 8 - Post CQC Immediate actions What to do in open cases where information on risk is currently stored elsewhere on the system or no risk assessment/plan has previously been recorded: Where Risk information exists on the system and is valid but not under the Risk Tab: All Information must be copied/rewritten into Carenotes risk forms. For all cases without a valid Risk Assessment or no Risk Assessment on the Carenotes system: Risk Screening must be completed for all cases If this triggers a comprehensive assessment you must make contact with the service use and if appropriate family and carer and consider a face to face appointment to review risk and complete the Comprehensive Risk Assessment Kate Hunt Lead Clinical & Forensic Consultant Psychologist Nikki Jones Lead Nurse Quality Compliance Minimum Risk Screening/Assessment recording Standards Version 2 Page 10