Health Record Policy for Mental Health and Addiction Group
MHAPPM/8046
General Manager - Mental
Approved by:
First Issued: March 2006
Health & Addiction Group
Review Date: April 2022
Signature:
David Warrington
Next Review: April 2028
Purpose
The purpose of this document to describe and define the minimum documentation standards and
requirements for Mental Health and Addiction Group.
This document is to be used in conjunction with MHAPPM/8953 – Mental Health Service Policy which
outlines the shared vision and expectations for the direction, values, principles, attitudes and ways of
working to deliver a values based service.
Scope
All Mental Health and Addiction Group staff
All Non-Government Organisations (NGO) who use the DHB’s patient management and clinical record
systems i.e. ‘Electronic Clinical Application’ (ECA) and ‘Clinical Portal’.
Definitions
Refer to the Mental Health Service Definitions Glossary
\\FS3\share\Public\All Users\MHS Policy review\DEFINITIONS FOR WORDS AND TERMS IN USE WITHIN THE
MENTAL HEALTH SERVICE.docx.
Roles and Responsibilities
Role
Responsibility
Clinical Manager/General
Ensure all staff are informed of the service documentation requirements and
Manager/NGO Manager
ensure compliance to this policy
Triaging clinician
Ensure completion of first contact/registration form, at the time of the first
contact
Commence the ‘Comprehensive Assessment’
Key Workers
Are service providers who coordinate communications and activities for the
Tangata whaiora in order to meet the goals described in their plan
Ensure Tangata Whaiora’s documents/diagnoses/health records are
accurately maintained, regularly reviewed, and are available to the right
people at the right time so decision makers are properly informed
Are the single or main point of contact for the Tangata Whaiora/family/
whānau, during service provision
Ensure health records are completed within prescribed time limits and are
available via the electronic patient management systems i.e. ‘Electronic
Clinical Application’ and/or ‘Clinical Portal’
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Role
Responsibility
Key Workers (continued)
Develop the plan in partnership with the person who is using the service and
his/her support people, where possible. Update the plan as frequently as
indicated in the Key Worker Procedure and as outlined in this policy (refer to
sub-heading ‘Go to Plan’ below)
Ensure all applicable Outcome Measures (Health of the Nation Outcome
Scale and/or Alcohol, and Drug Outcome Measure) are collected as per the
appropriate information collection protocol
Where a staff member has been allocated the Key Worker responsibility but
is not a registered health practitioner, a registered health practitioner must
also be allocated to supervise the care given by the non-registered person
i.e. the Key Worker. The Key Worker must have access to all clinical
documentation to ensure that comprehensive assessment is completed and
a Plan is developed and implemented
Ensure the Tangata Whaiora’s Supplementary Consumer Records are kept
continuously up to date
Ensure the Tangata Whaiora’s ICD Code(s)/Diagnosis(es) are recorded as per
points 25, 26 and 27 below.
Mental Health Service
Ensure health records are kept continuously up to date
and Non-Governmental
Organisation staff
HBDHB Standards
1
The Mental Health and Addictions Service recognises that the recovery of each person using the
Mental Health and Addictions Service is dependent upon excellent clinical practice and that their
health record must evidence comprehensive, organised information that reflects safe, efficient and
effective practice
2
Record keeping is essential in order to deliver safe and effective services that clearly identify the
strengths and risks that may affect a person’s recovery. All people who are referred to mental health
services must have the following forms completed and stored in their electronic health record:
a.
General Information Form
b.
Comprehensive Assessment
c.
Go To Plan
d.
Outcome measures:
i)
Health of the Nation Outcome Scale (HoNOS)
ii) Alcohol and other Drugs Outcome Measure (ADOM)
e.
ICD Code/Diagnosis(es) (International Classification of Diseases)
i)
This code (or multiple codes) must be recorded in the ‘Add/Change Diagnosis’ screen
within the ‘Primary Referral’
f.
Supplementary Consumer Records
g.
Discharge Summary Letter
3
Dependant on the needs of individual, the completion of additional documentation may also be
required, examples include, but are not limited to:- Clinical Risk Assessment forms, (refer to
MHAPPM/8102 - Clinical Risk Management System (CRMS) Procedure and/or Mental Health Act
Forms (refer to HBDHB/CPG/073 - Mental Health Act (1992) Initiating Urgent Compulsory
Assessment
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4
Each document must be completed and (where applicable) reviewed (using ‘Portal Forms’ within
‘Clinical Portal’) within the following described time limits.
First Contact and Registration Form
5
To be completed by the end of the clinicians’ duty, following the first face to face contact
6
The information contained in this document is to be transferred into the person’s health record in
ECA
7
Once the information is viewable via ECA, then any paper version can be destroyed
General Information Form
8
To be completed by the end of the clinicians’ duty, following the first face to face contact
9
This document is to be viewable via the person’s NHI number in ECA (may need to be scanned and
saved)
Comprehensive Assessment
10
To be completed by the registered health care practitioner:
a.
Inpatients : within 24 Hours or
b.
Community patients : within the first three face to face contacts (or two weeks – whichever is
sooner
11
This document is to be kept continuously up to date
12
The Key Worker must review this document at least once every three months (in collaboration with
the person where possible) and make an entry into the clinical notes to evidence that it has been
reviewed
13
This form is to be viewable via the person’s NHI number in ‘Clinical Portal’
14
Once the document is viewable via ‘Clinical Portal’ then any paper version can be destroyed
The ‘Go To Plan’
15
Community:
a.
The ‘Go To Plan’ must be documented within the first three contacts (including any type of
contact) and reviewed at least once every three months thereafter or as circumstances change
16
Inpatients:
a.
The ‘Go To Plan’ must be documented within 24 hours and reviewed at least every day
thereafter
17
The ‘Go To Plan’ must be updated during the two weeks prior to closing the Primary referral and
must include the plan for transiting from Mental Health and Addiction Services to the care of their
General Practitioner
18
This document is to be viewable via the person’s NHI number in ‘Clinical Portal’
Health of the Nation Outcome Scale (HoNOS/HoNOSCA/HoNOS 65+)
19
To be completed according to the ‘Information Collection Protocol’
20
To be completed in the electronic patient management system (i.e. ‘ECA’)
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Alcohol & Drug Outcome Measure (ADOM)
21
To be completed following the 2nd face to face encounter with an ‘Addiction’ type case team
22
To be completed according to the ‘Guide for Addiction Practitioners’
23
To be completed in the electronic patient management system (i.e. ‘ECA’)
Supplementary Consumer Records
24
The Key worker must keep these records continuously up to date and update these records as and
when changes occur
ICD Code/Diagnosis(es)
25
A minimum of one ICD code must be recorded in the ‘Add/Change Diagnosis’ fields by the end of the
shift during which the assessment took place
26
Up to six ICD codes/diagnoses can be recorded simultaneously within the ‘Add/Change Diagnosis’
fields contained within the ‘Primary referral’
n.b. also include all physical disorders when recording ICD codes/Diagnosis(es)
27
The person’s diagnosis(es) must be kept continuously up to date as and when changes occur
Discharge Summary Letter
28
It is a requirement that each person referred back to Primary Care at the end of their mental health
and/or addictions treatment receive a discharge summary letter to be handed to or mailed to the
person prior to closing the Primary referral
29
The letter must also be copied to the person’s General Practitioner. The summary letter should
include ongoing arrangements, how to regain entry to the service and who to contact at a later date
if required. (Refer NZS 8134:2021 Section 3.6 “Transition, transfer and discharge”).
30
Consideration must also be given to informing the initial referrer
31
All documents must be updated as information and/or the situation changes
Measurable Outcomes
Health Records will be audited annually.
Audit results will routinely be made available to clinicians within four weeks of audit completion.
Health record audit results will inform continuous improvement.
Related Documents
MHAPPM/8953 – Mental Health Service Policy
HBDHB/OPM/033 - Privacy Policy
HBDHB/OPM/074 - Health Record Policy
HBDHB/OPM/075 - Health Record Policy - Storage Security Accessibility and Off Site Storage
Health Practitioner’s Competence Assurance Act 2003
Privacy Act 2020
Health Information Privacy Code 2020
Health & Disability Commissioner (Code of Health & Disability Services Consumers’ Rights) Regulation 1996
HoNOS family of measures | Using Measures to Enhance Outcomes | Te Pou
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References
New Zealand Standard: Health Records 8153: 2002
HoNOS family of measures | Using Measures to Enhance Outcomes | Te Pou
Alcohol & Drug Outcome Measure (ADOM) - Guide for Addiction Practitioners
'Health and Disability Services Standard 8134-2021’
International Classification of Diseases – World Health Organisation
Keywords
Records
Record-keeping
Documentation
File
For further information please contact the
Quality Systems Manager - Mental Health and Addiction Group
Hawke’s Bay District Health Board
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