A Conversation about Documentation in Consultation Liaison

De-identified info from the ACMHN Consultation Liaison Nurse Network www.acmhn.org/home-clsig

PPT slide from the report given at the Australian College of Mental Health Nurses Consultation Liaison Special Interest Group Annual General Meeting on 5th June 2008.

Question from regional Queensland 06/02/18

My team serves two digital masters: CIMHA (the mental health only file/application) and ieMR (the electronic general hospital file/application).

Our flesh + blood masters have now suggested that we should stop documenting in ieMR.

I think that’s dangerous.

However, I  want to see if there’s any CL service(s) that does NOT document in the hospital file.

If so, how does it work? Do you spend a lot of time in coroner’s court?

Response from Melbourne 06/02/18

I can’t imagine not documenting in hospital/clinical file – what part of consultation are they missing?

Sorry – this is a redundant reply to your question but can’t not respond.

Response from Melbourne 06/02/18

I agree it is dangerous and wrong. If we don’t write in the hospital file, how do our referees know what we advise, how else do we educate them? The nurses would often tell me that they loved reading my notes as it helped them make sense of what was going on. Definitely fight it. Do the other consult teams to the hospital have a separate file? I doubt it.

Response from regional Northern Territory 06/02/18

The other justification is documenting a diagnosis for clinical coding, which may or may not be relevant to activity based funding depending on where you are working.

The issue we have found in the NT with printing notes from an electronic system and placing them in the paper file, is the mental health notes often go missing, are filed incorrectly or do not even make it to medical records after discharge, meaning our input, suggestions and recommendations don’t make it into discharge summaries or correspondence for future presentations. Hence why we also handwrite in the file.

Response from Perth 06/02/18

I agree with you – I think it is dangerous to say the least.

We currently primarily document in the general hospital file (as these patients are admitted under general medical teams) as the teams who refer to us are asking for advice, suggestions or assistance with these patients.  We do not admit these patients to MH and have no beds.  If we assess that the patient requires a MH admission only then do we refer and  complete the required MH documents (which would go with the patient to MH).  We are however, required to enter our patient contacts in to the statewide MH database in order to generate statistics for our service.

Response from regional New South Wales 06/02/18

I am lucky as we do not use the local MH electronic documentation system. Our patient files are still paper based. I would be concerned about the medicolegal aspects of not having your notes available to the general hospital staff.

Response from Adelaide 06/02/18

We use both systems (MH Community AND hospital EPAS).

Hospital is where we work; therefore MH record gets ‘cut and pastes’ for ongoing CMHT requirements (if at all)

Response from Brisbane 06/02/18

Given our clients/customers are the treating medical/surgical team it’s imperative we write all our notes within the clinical chart. At this hospital all clinical notes are uploaded into iEMR once the patient is discharged; this means our notes can be accessible by anyone with access to this system. As yet we don’t directly input notes into iEMR but I think over the years this will change.

Because our notes are also useful to MHS we either write directly into CIMHA, print off the note and put it in the clinical chart or print off the note we’ve written in the clinical chart and then upload this into CIMHA.

If a patient is clearly delirious with no mental health history we don’t usually upload anything into CIMHA, we just write in the clinical chart.

It’s helpful for the referring teams to be able to ALL aspects of a patient’s care during in-patient stays, including MH input as when the patient is next admitted it gives them a more holistic view of the patient and encourages them to think more about how their MH problems may impact on their admission.

Response from Brisbane 06/02/18

I write in the hospital chart Progress Notes and then scan and upload to CIMHA the electronic MH record.  The reason I do this is because CIMHA printouts get filed under correspondence and not chronologically in the Progress Notes of the patient chart.  I often have the debate with MH clinicians who see a patient in ED or a general ward on the weekend, come back and write an excellent entry on CIMHA but the receiving medical team has absolutely no idea that the patient has been seen, what the outcome was nor any plan for ongoing review.

My concerns are:

how are any risk issues handed over to the medical areas? If an adverse event like a suicide/attempt happened would the coroner think notes on a database not accessible from the current treatment are or team or the current record be seen as satisfactory?

the medical team who owns the patients care within the care structure and has asked for the MH input gets no report, feedback nor result from their request,

how do any recommendation get carried over?

I would also ask how MH would feel if cardiology came to review someone in the MH unit and returned to cardiology, noted their review on a bespoke cardiac notation system and not the record within MH and left it at that, if that would be seen as satisfactory practice and care.

I suspect the scope to debate this would be well achieved through the accreditation standards, documentation and/or handover, would this pass the accreditors?

Response from regional New South Wales 07/02/18

I agree with the observation made regarding fact that the treating team caring for the person must be aware of all essential clinical details and interactions that all clinical services are providing to the person.

For services that maintain separate mental health and medical records it is essential that the clinicians responsible for that episode of care (i.e. the inpatient staff) have ready access to the clinical record in the location they would be presumed to be consulting. I would strongly suggest this means mental health consultation notes should be entered into the ward medical record and a copy be provided to add to the mental health record.

I have been aware of MH clinicians and managers occasionally expressing anxiety about non-specialist health staff accessing mental health documentation for fear that clinicians will inappropriately access and use such information. All health employees in Australia are bound by a code of conduct which strictly prohibits the inappropriate access to and use of privileged information from a clinical record – the consequences of breaching this element of the code of conduct can be quite serious. One of the benefits we have in our health service in NSW is that the majority of our services are now recording in common electronic files (EMR), meaning the issue of which file to record a clinical intervention in is not an issue, and any time a clinician accesses those records a digital finger print is left on the file. This means any time a clinician accesses a file without just cause there is evidence that a breach of confidentiality has occurred.

Response from regional New South Wales 07/02/18

It is interesting this discussion has arisen now as it has been the hot potato topic of our area and specifically my role in recent months.

Prior to the review I had been documenting in the clinical file AND our electronic community record CHIME, double dipping if you please, and very time consuming.

It is now the case that I write in the clinical notes, but I will also in addition complete a form based comprehensive mental health assessment for those patients who are being referred to the MHS. That form is scanned and emailed to an email address specifically set up for each CMHT, it is then added to the electronic file, the original assessment form remains with the patients hospital file as correspondence.

Response from regional Queensland 07/02/18

CLP writes notes in CIMHA and places them in the medical record in the relevant admission or community section of the medical note. This seems to flow smoothly here and has the advantage that if the consumer is discharged to a rural area the CLP notes are available to general hospital staff in the viewer. We use the CLP templates  which are in CIMHA.

The community mental health teams no longer write notes in medical records. Their notes are all recorded in CIMHA and no hard copy is placed on the medical record.

Response from Melbourne 07/02/18

We used to have two separate files but now have EMR and record directly on to the medical file under mental health (there is a function to put it “behind the glass”) so you can record more sensitive information if necessary. Someone has to “break the glass to look at it”.  We’ve had this system now for about 18 months and it has cut down our paper work enormously.

Anyone we refer within our region to the community can be accessed through their own service on EMR and we link our referral to the UR of the patient.

If they are referred to another service (outside our region) we print out and fax our assessment to them from EMR.  Everyone we see is recorded on CMI (demographics, clinician, contacts, diagnosis, advance statement etc but we don’t record assessments or impressions there.)

So just for those in Victoria, so you know, once they hit the adult system you will be able to see their registration date etc and can always make contact for more info.

Response from Sydney-based, covers many NSW Local Health Districts (LHDs) 07/02/18

This thread is particularly useful, thank you!

The clients/patients we see via telehealth, have an open encounter/MRN/electronic Medical Record (eMR) – including community/inpatient – in the referring/responsible LHD, and we need to create a new encounter/MRN/eMR in my LHD. I then extract notes from eMR, create a letter of feedback (impression and recommendations) which I email same day, with request that the MH Clinician at the other end upload the feedback into their local eMR, then to maintain privacy, delete the email and attachment from their inbox and deleted folders.

Uploaded files/feedback appear in ‘correspondence’ which as pointed out in this thread, need to be hunted for. Getting the feedback into the eMR also relies on the receiving Clinician to access their email and process it.

Many of the women we see are at high risk of relapse or first episode psychosis around the time of childbirth so Maternity Services would benefit from seeing our notes.

I have taken initial steps toward a pilot project whereby we may be able to write directly in the eMR in the other, usually rural LHD.

Response from Melbourne 07/02/18

We document in the hospital paper file in the episode of care.

Simple.

It works for us but we are getting an electronic medical record “soon”

Response from Sydney 09/02/18

Our system here is all eMR and went this way last year with MH going this way before the major hospital. So anyone can see anything from D&A, MH, general inpatient and community services. There are just a couple systems that work differently (oncology – which includes our psych oncology outpatient) and maternity.

It has made life so much easier to be able to see recent interactions and it has also stopped the need to fax assessments etc as it can be seen.

Like others, if it is an individual who is from outside our area health, we fax it and give verbal handover.

Prior to this, we only ever wrote in the medical file as they are the services that we work with. We use to fax to same AHS but no longer do this 🙂

I would be very worried for all the reasons that others have stated in relation to medico-legal issues as well.

Response from regional Queensland 09/02/18

Thanks to everyone for your generous and thoughtful responses.

I had been given the impression that there was something peculiar about my stubbornness on the matter. The reassurance and wisdom of the CL Nurse community is very much appreciated.

Attached is a deidentified version of our conversation about documentation in consultation liaison.

The title will make for a good rap refrain.

I’ve left-out names of people and hospitals/districts, and the side-conversation re timeliness (no offence meant; hopefully none taken).

I didn’t ask the question to gather data for a conference presentation, but I might use the attached for something more academic than a funky rap refrain.

If you’d rather your info be excluded please contact me directly (off-list).

The Mental Health Consultation Liaison Nurse Network started-off in 2002 as a Yahoo email list. More info: http://www.acmhn.org/index.php/home-clsig

End

Many thanks to all those who participated in the email discussion. I’m reminded of our old flyer for the email network which was headed by this catchphrase:

Consultation Liaison Nurses.
Isolated Geographically. Connected Electronically.

I’m leaving the transcript of the conversation here for three reasons:

  1. There may be others who battling the same/similar issues. This page is googleable, so may be of assistance.
  2. The conversation isn’t about nuclear missile launch codes. There’s no need to keep it secret or hidden away from the world.
  3. I, and others who are interested, will be able to find the conversations (ie: qualitative data) quickly and easily PRN.

To find out more about the Australian College of Mental Health Nurses Consultation Liaison Special Interest Group and/or the email network, go to: www.acmhn.org/index.php/home-clsig

As always, your comments and feedback are welcome in the space below.

Paul McNamara, 20th February 2018

Short URL: meta4RN.com/documentation

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