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CHHS18/054

Canberra Hospital and Health ServicesOperational Procedure Clinical Handover – Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Introduction............................................................................................................3

Section 2 – Clinical Handover for Mental Health Services.........................................................4

Clinical Handover for new referrals.....................................................................................5

Section 3 – Clinical Handover – Brian Hennessy Rehabilitation Centre (BHRC)........................6

Section 4 – Clinical Handover: Crisis Assessment and Treatment Team (CATT)........................7

Handover Meeting Times....................................................................................................8

Primary Functions of Handover:..........................................................................................9

Section 5 – Clinical Handover - Registered Nurses (RNs) at the Alexander Maconochie Centre (AMC) and Bimberi Youth Justice Centre (BYJC).....................................................................10

Bimberi Youth Health Centre............................................................................................10

Hume Health Centre at the AMC......................................................................................10

Section 6 – Clinical Handover – Alcohol and Drug Services (ADS) Consultation and Liaison Service.....................................................................................................................................13

ADS Consultation and Liaison Service (CL)........................................................................13

Section 7 – Clinical Handover – Dhulwa (Secure Mental Health Unit)....................................13

Clinical Transfer from DMHU............................................................................................13

Admission from or Transfer to AMC or BYJC.....................................................................14

Clinical Handover within DMHU........................................................................................14

MDT morning handover DMHU........................................................................................16

Section 8 – Clinical Handover – Care of a person accessing Community Mental Health Services when the treating clinician is on leave......................................................................16

Planned Leave...................................................................................................................16

Unplanned leave...............................................................................................................17

Clinician returning from leave...........................................................................................18

Extended periods of leave.................................................................................................18

Doc Number Version Issued Review Date Area Responsible PageCHHS18/054 1 15/02/2018 01/02/2020 MHJHADS 1 of 23

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Implementation...................................................................................................................... 18

Related Policies, Procedures, Guidelines and Legislation.......................................................18

Search Terms.......................................................................................................................... 19

Attachments............................................................................................................................20

Attachment 1 - (I)SOAP Documentation............................................................................21

Attachment 2 – ISBAR Template.......................................................................................23

Attachment 3 – Clinical Handover Template.....................................................................24



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Purpose

This document is in addition to the Canberra Hospital and Health Services (CHHS) Clinical Handover Procedure to include specific information for MHJHADS. It is to provide accurate, accessible and timely transfer of clinical information for safe and effective clinical handover of people’s care in the clinical setting in the division of MHJHADS.

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Alerts

It is important to inform the people accessing services and their carers of all changes in arrangements associated with and throughout the clinical handover process.


Scope

This Procedure applies to all Mental Health, Justice Health, Alcohol and Drug Services (MHJHADS) clinical staff that provide clinical care and the transfer of clinical care from one clinician to another.


Section 1 – Introduction

Clinical staff working in MHJHADS are required to follow the Canberra Hospital Health Services Clinical Handover Procedure including utilisation of ISBAR template (see Attachment 1) and/or (I)SOAP (see Attachment 1) as required. In addition, MHJHADS staff are required to implement the clinical handover processes that are specific to the following clinical areas: Clinical Handover – Assessment documentation for clinical handover for Mental Health

Services (section 2). Clinical Handover – Brian Hennessy Rehabilitation Centre (section 3) Clinical Handover - Clinical Handover - Crisis Assessment and Treatment Team (section

4). Clinical Handover – Registered Nurses at Alexander Maconochie Centre (AMC) and

Bimberi Youth Justice Centre (BYJC) (section 5). Clinical Handover – Alcohol and Drug Services (section 6) Clinical Handover – Dhulwa, Secure Mental Health Unit (section 7) Clinical Handover – Care of a person accessing Community Mental Health Services when

the treating clinician is on leave (section 8)



This Standard Operating Procedure (SOP) describes for staff the process to

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AlertIf the team receiving the referral decline to accept, the Team Leaders/Managers and/or Consultant Psychiatrists or other Medical Specialists for the two areas need to communicate directly to maintain effective communication and the person’s safety. In the event that an agreement is not reached at the team or unit level, the matter is to be referred to the Operational and Clinical Director for each Program.


Section 2 – Clinical Handover for Mental Health Services

1 Clinical Handover for existing people/persons Clinical handover in mental health services is required in the following circumstances when the care of the person passes from: One service element (team, unit or program) to another service element (team, unit

or program); One clinician to another, either when a person is transferred from one team to

another team or when transferred within the same team; One clinician to another when a clinician takes leave and when the clinician returns

from leave; One MHJHADS element, program or unit to a community agency or General

Practitioner.2 As per the Health Directorate Clinical Handover Procedure the ‘ISBAR’ tool should be

used as a minimum to guide the structure and content of any clinical handover. The ISBAR tool refers to: I – Introduction S – Situation B – Background A – Assessment R – RecommendationAlso see ISBAR at Attachment 2.

3 Clinical documentation should be completed at the time of clinical intervention. If this is not possible, documentation must be completed before the end of the shift in which the clinical intervention occurred.

AlertNo copying and pasting of patient information is permitted. It is the expectation that clinical staff provide a contemporaneous account of the patient’s status from that shift which is accurate and succinct.

The Adult Mental Health Unit (AMHU) nursing file note includes the following: Documentation is to be organised according to the (I) SOAP tool headings (see

Attachment 2)



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4 A client meeting involving the referring clinician and the incoming clinician is generally arranged with the consumer (and carer/s), prior to the transfer of care in order to introduce the new clinician as part of the care team.

5 People/persons and carers should be kept informed of all changes in clinical care and throughout the clinical handover process.

6 The referring program/clinician needs to ensure all relevant documentation is completed to facilitate an appropriate transfer of care. This documentation includes a comprehensive assessment including formulation and diagnosis, outcome measures, and a suicide risk assessment.

7 In those rare cases, where a clinician leaves a service unexpectedly or without sufficient time to prepare a consumer for change in clinical management, the newly assigned clinician will rely predominantly on the information contained in the electronic medical record for the handover process and will contact the consumer/carer as soon as possible to explain the reasons for the transfer of care.

Clinical Handover for new referrals1 Clinical Handover of information relating to new referrals

Must involve transfer of all relevant information relating to the initial assessment. Assessment refers to the process of interview, collateral information collection and clinical formulation with documentation of all relevant information into the electronic record.

2 For new presentations at Community Teams Prior to presenting any assessment at the multi-disciplinary team meeting, the following must be completed: Electronic Record Full Assessment module including a written formulation; Documentation of collateral information and input received from carers/family; Suicide Vulnerability Assessment Tool (SVAT) completed; Outcome Measure/s; Clinical Plan; and Provisional Diagnosis.

3 Discharge from inpatient facilitiesIn accordance with the National Standards for Mental Health Services, all people/persons must receive follow-up within seven days after discharge from an inpatient facility wherever possible. The clinical handover from the inpatient facility to the relevant community mental health service must support this requirement and more specifically should provide direction as to the nature and frequency of the contact required over this 7 day period. A medical Discharge Summary is completed according to the requirements CHHS Discharge Summary Completion Procedure.

4 General Documentation Requirements for all Clinical HandoverAs part of clinical handover, clinicians are to check clinically-relevant components of Full Assessment Module to identify clinical risk and this includes the SVAT to be completed. Confirm or amend the Clinical Plan and record diagnosis in the electronic record. The Clinical Plan must define the level and type of contact recommended.



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NoteFor internal referrals if a comprehensive assessment has been completed in this episode of care and remains current, it is not to be duplicated but referenced by date and file title. Any updated information needs to be clearly file titled Assessment and any missing information such as Outcome Measures need to be completed to comply with the process outlined in this section.


Section 3 – Clinical Handover – Brian Hennessy Rehabilitation Centre (BHRC)

Clinical Handover for BHRC will include key information to be handed over for each person that is admitted. There are important safety and security issues that need to be handed over to the oncoming shift. These issues include: Duress alarms, drug keys Environmental/safety issues e.g. malfunctioning doors or locks, and repairs, which may

impact on care and the safety of admitted persons, staff and visitors Healthcare professionals or visitors present at BHRC or due to visit Events that may affect the running of the BHRC Unit dynamics – relational security

Clinical handover should occur during handover of care as per Section 1 – Introduction.

All handovers must be done in the Extended Care Unit (ECU) handover room rather than the individual villa to ensure that all staff receive information about all people/persons regardless of where staff are allocated for the shift.

The following ISBAR format is to be used as a guide for clinical handover:I – Introduction Person’s name / Identification of the person/ room number

Date of admission Diagnosis including physical illnesses key workerWhere applicable: Historical information

S – Situation Level of engagement and therapeutic observations, ADLS Reason or goal of admission Arc status and reason if reviewed/increased/decreased Leave status and whether leave was utilised



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B – Background Physical Health observations and physical health care issues Pathology, any outstanding results Medication – Issues, current medication and any changes Where applicable: Urinary Drug Screen Fluid balance chart, other monitoring charts Supervision required for cooking etc Fasting bloods Room Searches

A – Assessment Mental state and current functioning including levels of activity and engagement with team and peers, and participation in rehabilitation/recovery focused programs.

Presentation/ Accomplishments during this shift Any issues relevant to their current functioning and risk Risk management / Summary of identified risks and risk status and any

interventions (including incidents in the previous 24 hours / crisis intervention)

R - Recommendations

Summary of the plan of care and required interventions Updating staff on plans made in Multi-Disciplinary Teams (MDT) or care

reviews Summary of any adverse physiological status and management care

plan The allocation of tasks for the oncoming shiftWhere applicable: Any interventions that will impact on the staffing requirements (i.e.

escorts) / Appointments / Visits/ Court and ACAT hearings Discharge planning Strategies used to engage people in therapeutic activities Working with the person to meet their identified needs and health

goals Liaising with families – who did so and what was discussed Room Searches Urinary Drug Screen still to be given


Section 4 – Clinical Handover: Crisis Assessment and Treatment Team (CATT)

Standardised clinical handover processes for the CATT are required to ensure an appropriate transfer of clinical information and person care, across shifts during the 24/7 operations of an acute mental health service.

These handover processes utilise standardised multidisciplinary practises, and involve review of new assessments, care plans and clinical reviews as required for existing people, case closure reviews, as well as the prioritisation of work for the upcoming shift using the CATT Whiteboard system (see CATT White Board Procedure 5046).



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The clinical handover meetings will often involve Multi-Disciplinary Team (MDT) processes, including the Consultant Psychiatrist, Psychiatry Registrar, Team Leader, Nurses, Psychologists, Occupational Therapists & Social workers. However, the Team Leader, and Medical Officers are generally not available for those Clinical Handover Meetings occurring afterhours (i.e. on weekends, and after 5pm on weekdays). Any psychiatric/medical input required afterhours is sought from the on-call Psychiatry Registrar. AlertAn MDT review requires that minimum staffing must include a medical officer, as well as representatives from at least two other disciplines. Multi-disciplinary teams have the delegated responsibility to collaboratively manage the clinical aspects of people referred/allocated to their team’s service delivery.

Handover Meeting Times1. Night-Morning Triage Handover (0715 - 0730hrs)

CATT night staff provides clinical handover on any information pertaining to their overnight contacts with people during the Night Shift, particularly in relation to people who may require follow-up from CATT that day.

CATT night staff and the morning Triage staff ensure this information has been updated on the CATT Whiteboard and MAJIC eR file.

During the course of their shift, the Morning Triage/Through Shift staff are responsible for ensuring that all new referrals are added on the CATT Whiteboard and notifying the Shift Coordinator of same (see CATT Triage Procedure 4347).

2. Morning Handover (0800-0845hrs) Monday-Friday - Involves the full complement of morning staff of the CATT team

involving CATT clinicians, Consultant Psychiatrist, Psychiatric Registrar, CATT Team Leader and students unless otherwise engaged in other clinical activities or other duties.

On weekends the CATT Team Leader and Medical Officers will not be present for these meetings.

CATT staff designated as the Shift Coordinator is responsible for updating the CATT Whiteboard during the handover meeting (although may delegate actual task of entering information into Whiteboard to another staff member) and, with the assistance of their colleagues, ensuring all decisions made during the handover relating to a person’s care are clearly documented in the electronic clinical record. The Shift Coordinator is also responsible for the allocation of work among CATT clinicians.



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3. Afternoon Handover (1430-1515hrs) In addition to the morning handover process, the evening rostered CATT staff will

also be present during this handover meeting, which will also include the rostered morning staff (unless the staff member are engaged in clinical activities or other duties).

4. Evening Triage-Night Shift Worker (2300-2315hrs) The Evening Triage staff passes on any significant information to the Night Shift

worker pertaining to work of that evening as well as raising awareness of people who have been identified during the evening shift as being “vulnerable” or “at risk” (and subsequently, may require further CATT input overnight). This may include people awaiting assessment at the Calvary Emergency Department or City Watch house or other community location where safe and appropriate to do so (e.g. urgent joint home visit with Police). The Night Shift worker must consider use of the CATT on-call worker for such assessments.

The Evening Triage staff are responsible for ensuring that all new referrals have been added to the CATT Whiteboard and notifying the Shift Coordinator of this information.

The CATT Night staff will also be required to accept a handover from the Mental Health Emergency Department Consultation and Liaison evening or night worker who will provide information in relation to people who may still be awaiting assessment or review within the Emergency Department where the CATT Night worker/on call worker are required to assist in assessment.

Primary Functions of Handover:1. Review of New Assessments:

Assessment refers to the process of interview, collateral information collection and clinical formulation with documentation of all relevant information into the electronic clinical record.

For new presentations at CATT handover meetings, prior to presenting any assessment, the following should be completed: Electronic record (currently MAJICeR) Full Assessment module including a written

formulation, Outcome Measures – HoNOS (Health of the Nation Outcome Scales) Comprehensive Risk assessment including the SVAT Clinical Plan which must define the level and type of contact and impressions or

Provisional Diagnosis/Diagnosis (if consumer has been assessed by CATT Consultant Psychiatrist/Registrar or has a previous diagnosis as supported by collateral information from other sources e.g. private psychiatrist, interstate mental health service etc).

2. Ad hoc and Planned Reviews CATT staff may present any persons requiring urgent MDT input for and the level of clinical response must be determined and actioned by the team.



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3. Case ClosuresMust involve MDT process (see Standard Operating Procedure: Case Closures)

4. Work prioritisation and allocationAs described above, the Clinical Handover Meetings are also used to prioritise the work demands for each shift, with consideration obviously given to Triage Response Categories, potential risk issues, and other factors including staff skill-mix.


Section 5 – Clinical Handover - Registered Nurses (RNs) at the Alexander Maconochie Centre (AMC) and Bimberi Youth Justice Centre (BYJC)

To ensure effective clinical handover occurs between the morning and evening shift to provide information on the health requirements of people at AMC and BYJC.

This section of the procedure pertains to health professionals working at the AMC and BYJC.

Bimberi Youth Health Centre JHS nursing staff attend a brief with BYJC staff each morning at 0815. This ensures JHS

staff are aware of any concerns or issues that occurred overnight. BYJC may also communicate with JHS clinical staff via the

[email protected] email. The Bimberi nursing staff check this inbox daily.

The following emails are used by JHS staff to contact BYJC staff: #[email protected]; #[email protected]; #[email protected]

• Communication between JHS nursing staff occurs electronically via direct email to the rostered JHS nurse and all clinical information can also be accessed via MAJICeR process note entries.

Hume Health Centre at the AMC1. JHS Clinical Handover Book

The JHS Clinical Handover Book is located with the staff shift diary. It is the responsibility of the CNC / shift leader to ensure the book is completed at

the end of their shift Each morning it is the responsibility of the CNC / shift leader to review the previous

day’s handover page to ensure all follow up required is completed.2. JHS Clinical Handover Whiteboard

The JHS Clinical Handover Whiteboard is utilised to record important information for the following shifts.

It is the responsibility of the CNC / shift leader to ensure that the whiteboard is up to date at the completion of their shift.

JHS Clinic (Doctor/Dental/Mental Health) Handover Books



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Utilising the ISBAR format, it is the responsibility of the medical / mental health / dental clinician to complete the handover book each day.

It is the responsibility of the CNC / shift leader to review the clinic handover books prior to the completion of their shift for follow up that needs to be attended.

Daily handover All nursing staff present will attend handover. Handover will occur in a secure and confidential area. Suggested time for handover is 1245 to 1300 depending on operational requirements. Handover will be led by the Clinical Nurse Consultant (CNC) or morning shift leader. The Justice Health Services (JHS)Clinical Handover Book will be taken to Handover. The

CNC or shift leader will be responsible for updating the clinical handover book. Each rostered shift will handover using the following format:

o Missed methadone / clients to be brought to the health centre for S8 medicationso Clients that have missed their morning medicationso Clients of concerno Follow up information

The CNC / shift leader will be responsible for handing over:o Clients that need to fasto Clients that have been transferred to hospitalo Updates on clients currently in hospitalo Updates on clients reviewed in the doctor/dental/pharmacy/mental health clinicso Any changes in daily work routine/instructions.

Medical officers will be responsible for handing over:o Updates on clients that they have reviewed in their clinic

Evening handover The evening shift leader is responsible for recording any relevant issues concerning

clients in the JHS Clinical Handover Book The JHS Clinical Handover book is to be left with the daily shift diary. The nurse responsible for induction assessments is responsible for sending an electronic

handover to all JHS nursing and medical staff. The following format should be utilised:o Name and ageo Housing location if knowno Significant medical historyo Drug and alcohol historyo Withdrawal observationso ACT Corrective Services medical observations recommendedo Additional follow up required

It is the responsibility of the admissions nurse to document in the JHS Clinical Handover Book the number of admissions they have completed.




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Section 6 – Clinical Handover – Alcohol and Drug Services (ADS) Consultation and Liaison Service

ADS Consultation and Liaison Service (CL)To ensure effective Clinical Handover occurs between each shift, 7 days per week using the CL electronic handover tool.i. At 0830hrs, Monday – Friday the Manager of CL provides daily updates of current people

referred to ADS CL. This information is updated on the electronic handover tool which reflects the ISBAR philosophy.

ii. Referrals are prioritised to include those people who require immediate assessments prior to ward rounds, follow up phone calls, and allocation for ward rounds.

iii. At 1000hrs the ADS Addiction Specialist is provided with a handover via the whiteboard tool for people admitted to CHHS who require support for substance use issues. This will relate primarily to the ward round and for consultation around care and management of people who have been or will be seen by CL outside ward rounds. This handover is signed off on in the CL diary. The whiteboard i.e. the handover tool is updated as possible to include the latest CL interventions.

iv. 1530 hrs on Thursday, Friday and Saturdays only - Verbal handover using the electronic handover tool will be conducted with the CL Manager and the morning CL nurse. At the end of the afternoon shift – the whiteboard will be updated to show CL interventions including ward rounds, phone calls, and brief interventions.


Section 7 – Clinical Handover – Dhulwa (Secure Mental Health Unit)

Clinical HandoverClinical Handover will be provided by a representative of the referring team at admission, if possible, and this should be confirmed prior to admission. The handover will follow the ISBAR (Introduction, Situation, Background, Assessment and Recommendation) format and should be done in person, by the person accompanying the consumer and should be documented in the ECR. If possible, the consumer should be involved in the handover.

Clinical Transfer from DMHUTransfer from DMHU i.e. discharge planning will require regular liaison with the consumer, their primary mental health clinician, transition clinician, family, carer and nominated person, General Practitioners (GP) and medical specialists, community sector agencies and other relevant supports. As part of discharge planning, the expectations and required outcomes expected prior to discharge should be negotiated with the consumer, their families and carers, and any other support services or networks.

In preparing for discharge: Members of the receiving team will be encouraged to visit the consumer at the DMHU

prior to transfer.



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Therapeutic leave to the post-discharge accommodation will be arranged to introduce the consumer to the new treating team and allow for any questions either party may have, where appropriate.

Discharge summary should be completed within 48 hours of discharge as per the Discharge Summary Completion Procedure. When completing the discharge summary ensure that the client’s GP (or facility the client is being discharged to) is known, so that the GP may receive a copy.

Transfer to another ACT Mental Health Facility or Community Care ServiceThe decision to transfer a consumer to another ACT Mental Health Facility or service will be agreed at a MDT/Ward Round/Case Review Meeting by the MDT/WR. Following this, an application will be made to the AAP. Where appropriate, family and/or carers and/or nominated persons should be made aware of the plan to transfer and invited to attend the MDT/WR/Case Review meeting. In deciding to transfer the consumer, the MDT/WR/Case Review meeting must consider the type of facility or service that the consumer could be transferred to and the level of supervision or security appropriate to manage the consumer’s level of risk in that setting. In collaboration with the receiving health service, the consumer, their legal guardian and, where appropriate, family and/or carers and/or nominated persons, the MDT/WR will develop a transfer of care plan detailing: the consumer’s management plan (including wellness strategies); key referral services and programs (e.g. Detention Exit Community Outreach - DECO,

Housing and Accommodation Support Initiative - HASI); medical and community or other support follow-up arrangements; emergency contact numbers; contingency and relapse response plans; and security considerations.

See DMHU Referral, Admission and Transfer of Care Procedure for more detail about the transfer process.

Consumer on a Forensic Mental Health OrderWhen transferring a consumer on a FMHO from the DMHU to another ACT Mental Health Facility the Consultant Psychiatrist will complete the Forensic Treatment Plan and Location Determination Form, available on the clinical forms register.

Admission from or Transfer to AMC or BYJCArrangements for transfer to or from the AMC or BYJC for people/persons of DMHU are detailed in the DMHU Transfer of Custody Procedure.

Clinical Handover within DMHUClinical Handover for DMHU will include key information that is handed over for each person that is admitted. There are important safety and security issues that need to be handed over to the oncoming shift. These issues include: Security equipment, Pagers, two way radios, drug keys



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Environmental/safety issues e.g. malfunctioning doors or locks, and repairs, which may impact on care and the safety of admitted persons, staff and visitors

Healthcare professionals and visitors present on the unit or due to visit Events that affect the running of the unit and hospital Unit dynamics – relational security Scheduled visits, escorts and programs for the next shift

Please see the following example of clinical handover for DMHU. The DMHU clinical handover should occur at a minimum), but not limited to the following times: shift to shift handover return from leave when there is any change in presentation

Example of Dhulwa clinical handover - the following items must be handed over: I – Introduction Person’s name / Identification of the person

Date of admission Diagnosis including physical illnesses Legal Status / Index offence Leave Status Primary NurseWhere applicable: Historical information

S – Situation Level of engagement and therapeutic observations/prescribed observation levels, reasons if increased levels of observation

Reason for admission

B – Background Physical Health observations and physical health care issues Pathology Medication – Issues, current medication and any changes Where applicable: Urinary Drug Screen Room Searches

A – Assessment Mental state and current functioning including levels of activity and engagement with team and peers, and participation in rehabilitation/recovery focused programs.

Presentation Any issues relevant to their current functioning and risk Risk management / Summary of identified risks and risk status / DASA Scores

and interventions (including incidents in the previous 24 hours / crisis intervention)

Updating staff on plans made in Multi-Disciplinary Teams (MDT) or care reviews / Changes to TPRIM

R - Recommendations Summary of the plan of care and required interventions Summary of any adverse physiological status and management care plan The allocation of tasks for the oncoming shiftWhere applicable: Any interventions that will impact on the staffing requirements (i.e. escorts) /

Appointments / Visits



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Court and ACAT hearings Discharge planning Engaging people in therapeutic and diversional activities Working with the person to meet their identified needs and health goals Liaising with families Room Searches Urinary Drug Screen

Clinicians can use the handover sheet (see attachment 3) to document information that is handed over for the shift but need to ensure it is destroyed in the confidential waste bin at the end of the shift.

MDT morning handover DMHUAn MDT morning handover is conducted from 9am to 9.30am Monday to Friday. The MDT consists of a medical officer, and clinicians from at least two other disciplines. At this time the Nurse In Charge passes on any significant information pertaining to work of the previous evening and night shift, changes that effect relational security, including DASA scores, changes in presentation, unit dynamics and the plan for the day, including reviews.


Section 8 – Clinical Handover – Care of a person accessing Community Mental Health Services when the treating clinician is on leave

To ensure alternative and appropriate care arrangements are in place for people managed by MHJHADS community mental health services whenever their treating clinician is on leave (including planned and unplanned leave). It is the responsibility of the treating team to ensure that appropriate steps have been taken prior to the leave (or are taken as soon as possible, in the case of unexpected leave) such that processes are in place to support the ongoing provision of clinical care.

Planned Leave1. Prior to the commencement of planned leave a clinician must review their entire case

load to determine which people will require follow-up during their period of absence.

Alert: Particular attention should be paid to those people who are assessed as being at high risk (or likely to become high risk) of harm or deterioration in mental state, if not closely monitored and supported. Follow-up appointments with an alternative clinician and reallocation to another clinician for the duration of the leave period must occur prior to the taking of leave.

2. Prior to taking leave, the clinician must ensure wherever possible that all clinical documentation is up to date (i.e. where due for review) including completion of the person’s Recovery Plan, Outcome Measures, Suicide Vulnerability Risk Assessment, and Case Review. A clinician’s absence due to leave should not necessarily lead to the deferment of any part of a person’s Recovery plan. If actions are being deferred, a clear



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rationale should be provided for same and only considered where assessed as having no adverse impact on the person’s wellbeing.

3. The clinician should always advise the person, family/carer or other key stakeholder of the alternative clinician to contact for all people -related matters in their absence (e.g. the Duty Officer or other allocated clinician).

4. Any persons who require any form of contact during the leave period must be identified by adding their information to the Electronic Whiteboard of the relevant community mental health team. The information should include, at minimum: the name of the person; the person’s diagnosis/presenting problem; the treating clinician’s name and the alternative clinician to whom they have been

allocated; the date they were added to the whiteboard; the date and type of follow-up that is required (e.g. home visit twice weekly,

medication due or other intervention or meeting time); whether the person is subject to a Psychiatric Treatment Order; whether the person is identified as experiencing a deterioration in their mental state;

and Any other notes as indicated.

5. The clinician should give a handover for each person to the alternative allocated clinician. 6. The alternative allocated clinician’s name should also be registered on the electronic

clinical record database in the relevant “Assigned Staff” section. This is to assist other staff members in correctly identifying who should be notified in the event of any other information received in regard to a person’s care.

Unplanned leave1. In the event of a period of unplanned leave (up to 3 days) the Team Leader or delegate

(e.g. Duty Officer) will review the clinician’s scheduled appointments for each day.1.1. The Team Leader or delegate (e.g. Duty Officer) will then contact the affected people

to advise of cancellation of appointments or organise for them to see another clinician (e.g. Duty Officer) if indicated from contact or from information contained in the medical record which suggests more urgent action is required.

Alert: Particular attention should be paid to those people who are assessed as being at high risk (or likely to become high risk) of harm or of deterioration in mental state, if not closely monitored and supported. Follow-up appointments with an alternative clinician and reallocation to another clinician for the duration of the leave period must be prioritised and occur as soon as practicable when leave is identified.

1.2. The Duty Officer will also review the medication charts of people managed by the absent clinician to determine if any person’s medication is due on those days and make alternative arrangements for administration.

1.3. Any internal (e.g. Electronic Record messages) or external referrals relating to people managed by the absent clinician will be reviewed by the Duty Officer and responded to as appropriate.



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2. In the event of indefinite unplanned leave (greater than 3 days); or where planned leave has later been extended, the Team Leader with the Consultant Psychiatrist will review the caseload of the absent clinician to determine follow-up required.

3. As far as the steps are possible, without the person’s treating clinician being available, the same process as outlined above at “Section 1. Planned Leave” should then be replicated.

Clinician returning from leaveWhen the treating clinician returns from leave they should be given a handover of each person’s case from the alternative allocated clinician, with particular attention given to any significant events (past or upcoming) and any significant changes in the person’s presentation, treatment or recovery plans.

Extended periods of leaveIn cases where the clinician is on an extended period of leave greater than one month (e.g. Maternity leave, temporary secondment to another area), people should be categorically reallocated to another clinician and standard processes for management should then apply.


Implementation

The contents of this procedure will be communicated through training provided to MHJHADS staff and other relevant teams where the procedure applies.


Related Policies, Procedures, Guidelines and Legislation

PoliciesACT Health Work Health and Safety Policy ACT Health Work Health and Safety Management System ACT Health Incident Management Policy ACT Health Consumer and Carer Participation Policy

Procedures ACT Health Incident Management Procedure ACT Health Significant Incident Procedure CHHS Clinical Handover Procedure After Hours Director on Call – Reporting Process, Roles and Responsibilities MHJHADS Unauthorised Leave of Admitted People from MHJHADS Inpatient Units Incidents Reportable to the Executive Director and Intervention Following the Death of a

Person - MHJHADS Initial Management, Assessment and Intervention for People Vulnerable to Suicide Confidentiality, Privacy and Access to MHJHADS Clinical Records Daily Clinical Meetings in Community Mental Health Settings



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Clinical Management for Mental Health Services CATT White Board Procedure CATT Triage Procedure CATT Shift Coordinator Episode of Care Closure MHJHADS DMHU Transfer of Custody Procedure DMHU Management of Consumer Leave Procedure DMHU Referral, Admission and Transfer of Care Procedure Discharge Summary Completion Procedure

Standards National Standards for Mental Health Services National Safety and Quality Health Service Standards Australian Charter of Healthcare Rights Standards of Practice for ACT Health Allied Health Professionals

Legislation Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Health Records (Privacy & Access) Act 1997 Human Rights Act 2004 Corrections Management Act 2007 Public Sector Management Act 1994 Health Practitioner Regulation National Law (ACT) Act 2010 Health Practitioner Regulation National Law Act 2009 Health Practitioner Regulation National Law Regulation Work Health and Safety Act 2011 Carers Recognition Act 2010


Search Terms

Handover, Transfer of Care, ISBAR, (I)SOAP, Clinician on leave, AMC, Bimberi, CATT, SMHU


Attachments

Attachment 1 – (I)SOAP Documentation Attachment 2 – ISBAR TemplateAttachment 3 – Clinical Handover Template

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.



CHHS18/054

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 20/09/2017 15/02/2018 ED MHJHADS CHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/535 Clinical Handover within MHJHADS



CHHS18/054

Attachment 1 - (I)SOAP Documentation Documentation is to be organised according to the (I)SOAP tool headings:

o Intervention/IntroductionIdentify yourself and give your reason for the clinical handover or interventions planned

o Subjective informationPresentation of the consumer’s viewpoint – their story, how they may feel

o Objective information Objective observations of the consumer – factual, unbiased and measurable including Observations including MEWs score ARC scores and leave management BrØset score and management Assessment including Mental State Examination MSE:

- Appearance- Behaviour - Speech - Mood/Affect - Thought Content - Thought Form - Perception - Cognition - Insight

Episodes of seclusion / forcible giving of medications Medications including PRN and STAT dose provided during the shift or

medication refusal

o Analysis/action/advice Analysis and interpretation of subjective and objective information followed by action implemented and any related advice or education provided including but not limited to: Identification of risk Identification of deterioration Information to family / carers Referral to Allied Health team Request for Medical Consult Request for Consumer / Carer Consultant input

o Plan Plan of care to incorporate any required changes to interventions and time frames – includes changes to care plans including but not limited to: EDD Inpatient treatment planning



CHHS18/054

Discharge planning Identified blockages to discharge Referral for Complex Management Review Follow up with community agencies to support discharge planning



CHHS18/054

Attachment 2 – ISBAR Template



CHHS18/054

Attachment 3 – Clinical Handover Template



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