|Title:||State-wide Standardised Clinical Documentation (SSCD) for Mental Health Services.|
|Document ID:||Operational Directive OD 0526/14|
|Date of issue:||Wednesday, 4 June 2014|
|Description:||This Operational Directive requires that all Mental Health Services fully comply with the use of State-wide Standardised Clinical Documents. This is in line with the recommendations of the Stokes Review (July 2012) and to support the requirements of the Mental Health Bill 2013|
|Legal requirements:||Mental Health Bill (2013)
|Applicable to:||All Clinical staff working in public Mental Health Services in WA|
|Framework:||Mental Health Policy Framework|
|Period of effect:||from 4 June 2014 to 1 July 2020|
|Review date:||1 July 2019|
|Authorised by:||Professor Bryant Stokes, A/General Director, Department of Health, 16-May-2014|
|Print version:||View print version|
State-wide Standardised Clinical Documentation (SSCD) for Mental Health Services.
This Operational Directive requires that all public Mental Health Services (MHS) use the State-wide Standardised Clinical Documentation (SSCD) to document care provided by the multidisciplinary team.
The SSCD fulfils the priority recommendations made through the “Review of admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia” (Stokes, July 2012). The recommendations are outlined in the Table below:
The SSCD will enable the consistent recording, retrieval and sharing of medical record information at all points of care for the consumer from triage through to discharge. The primary goal is to improve mental health consumer health outcomes by enhancing the clinical information available to inform care decisions.†
The use of the SSCD is mandatory for all MHS.† The standardisation of clinical documentation improves patient safety and quality at their respective key points across the care continuum, in all MHS settings.†
The Office of Mental Health (OMH) is working with the Health Information Network (HIN) to progress the development of enhancements to PSOLIS to provide the whole SSCD suite in an electronic format as soon as possible.† This approach will significantly increase timely access to consumer care and management plans by clinicians across the public MHS.†
Effective immediately, all adult MHS will implement the mandatory SSCD, which includes:
Effective immediately, all child and adolescent MHS will implement the mandatory SSCD, which includes:
Three documents of the SSCD suite are currently required to be completed in PSOLIS:
The remaining documents: Assessment (CAMHS version titled - Initial Assessment), Physical Examination, Physical Appearance (Not applicable to CAMHS) and Care Transfer Summary are to be completed in paper-based format or the sanctioned writable PDF format until the full suite of SSCD are on PSOLIS. MHS can use other program-based documentation and contemporaneous progress notes to supplement information documented in the SSCD as appropriate.
The mandatory documents required in a Consultation Liaison Psychiatry Services (CL) setting are:
In a CL setting, the three documents can be completed in paper-based format, the sanctioned writable PDF format or on PSOLIS (if available). If the document is available on PSOLIS, PSOLIS is the preferred method. Use of other documents in the SSCD suite is optional.
All MHS are expected to implement the state-wide guidelines ‘Triage to Discharge Ė Mental Health Framework for State-wide Standardised Clinical Documentation’ (December 2013).† These guidelines address the minimum standards for the physical health care of mental health consumers in a public psychiatric inpatient facility in Western Australia.† This consistent approach will enable clinicians to embed the mandatory clinical documentation into practice, particularly addressing the sharing of medical records information between those service providers directly involved in the consumer’s care.
MHS are expected to familiarise themselves with other departmental policy, for the overall care and safety of mental health consumers, including:
The OMH, through the SSCD Implementation Group, will continue to facilitate the implementation process. The scope of work includes oversight of the ICT enhancements and the development of state-wide monitoring and reporting to demonstrate improvements in the standard of clinical documentation. All MHS are required to monitor the implementation of the SSCD.
Ordering and supply of the mandatory SSCD forms will take the usual process through the Print Media Group website (www.pmg.com.au) and follow local ordering procedures and approval processes.
FOR FURTHER INFORMATION
All enquiries about the SSCD for Mental Health should be directed to the Health Service’s Executive Director, Mental Health.
The Executive Director, Office of Mental Health is the second point of contact on (08) 9222 2171.
Professor Bryant Stokes
This circular last updated: Wednesday, 4 June 2014 at 2:31pm