mch cdis external referral process · mav mch cdis external referral process: sept 2016 making an...

September 2016

MCH CDIS EXTERNAL REFERRAL PROCESS

MAV MCH CDIS External Referral Process: Sept 2016 Page 1 of 15

Contents

Making an External Referral from Client (CHILD) Consultation ...................................................................................................................................................................... 2

Important Notes for Completing an External Referral ................................................................................................................................................................................................ 3

External Referral Pop-up Box from Client (CHILD) Consultation ................................................................................................................................................................................. 4

Using Referral Letter Template for External Referral from Client (CHILD) Consultation ............................................................................................................................................ 5

Example of Completed External Referral in Client (CHILD) Consultation .................................................................................................................................................................... 6

External Referral in Client (CHILD) Referral Screen – Editing & Completing ............................................................................................................................................................... 7

Example of Completed External Referral in Client Notes ............................................................................................................................................................................................ 8

Example of Completed External Referral in Client Notes – Editing External Referral Notes ...................................................................................................................................... 9

Example of Completed External Referral Notes Edited in Client History/Notes ....................................................................................................................................................... 10

Adding Referral Letters/Forms as Attachments to Client History ................................................................................................................................................................. 11

Viewing, Editing & Deleting Attachments in Client History ....................................................................................................................................................................................... 12

Adding ‘Referral Follow-up’ Blue Alert Flag for External Referrals ............................................................................................................................................................... 13

Update Status of External Referrals - Pending, Active, Completed or Declined ............................................................................................................................................ 14

Removing ‘Referral Follow-up’ Blue Alert Flag for External Referrals ........................................................................................................................................................... 15

MAV MCH CDIS External Referral Process: Sept 2016 Making an External Referral from Client (CHILD) Consultation Page 2 of 15

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Making an External Referral from Client (CHILD) Consultation

1. In Client History, hover cursor over Clinical Activity

Move curser down and Left click: Consultations Select and commence appropriate consultation

2. Complete consultation as appropriate

3. Click External Referral

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Important Note:

ALL Referrals (except Enhanced Maternal & Child Health Service) are recorded from the CHILD HISTORY

**Referrals are counted for reporting purposes from the Child History**

If the Referral is relevant to someone other than the CHILD (eg, Mother, Father, Caregiver):

1. Enter referral in CHILD History a. Document in Additional Comments, “attachments in [relevant client’s] history” b. Add Referral Follow-up Blue Alert Flag

2. Ensure that the relevant client is Open (eg, Mother, Father, Caregiver etc) 3. Document in the Notes of that relevant Client History:

a. Date referral made b. Name of Referee c. Brief referral reason d. Attachment of relevant documents/referral letter

i. Attach relevant documents/referral letter e. Add Referral Follow-up Blue Alert Flag

4. Document follow-up on status of referral in: a. Relevant Client History b. CHILD History

5. On closure of the referral, remove Referral Follow-up Blue Alert Flag from: a. Relevant Client History b. CHILD History

6. Close relevant Client History if referral closed and no further action is required


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Important Notes for Completing an External Referral

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1. Search by entering your Council name as Organisation

2. Click Search

3. Select appropriate Referee/Organisation That is, External Service Provider (as Last Name)

and your Council name (as Organisation)

4. Click Use service provider

The Referral Letter template is not professionally sufficient to send as a referral in its current form (see Using Referral Letter Template, p5). This referral letter template (viewed in Print preview) will be amended as a CDIS enhancement and will be available in the future.

Whilst the Referee is mandatory for filling out the screen, ONLY the Reason for referral is counted for reporting.

Searching, selecting and creating a Referee is currently problematic – this is being investigated and will be rectified. Please ensure you Select Referee as per the below process


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External Referral Pop-up Box from Client (CHILD) Consultation

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ALL referrals are counted for reporting purposes in the CHILD History (except Enhanced Maternal and Child Health)

ONLY the Reason for referral is counted for reporting purposes

1. Select Referee, by clicking the Select Referee button Refer to previous page: Important Notes for Completing an External Referral

2. Select Referral Reason(s) from look-up list More than one Reason can be selected Select one Reason at a time and click for each Multiple reasons can be selected, as all are counted even if to different Referees

3. Document referrals in Referral Letter free-text field That is: reason for referral, name of actual referee & referral letter attached

4. Ensure Staff member* is correct This is set by default to your settings

5. Ensure Letter date* is correct This is set by default to today’s date

6. Sending Attachments with referral Select by clicking Yes or No accordingly

7. Gain informed consent to referral Select by clicking Yes, No or Undecided accordingly

8. Click Save (no further editing) or Save and Continue (allows editing)

9. Attach relevant documents to Child &/or Relevant Client History: Council Templates or Independent Referral Letter Supporting referral documents

10. Ensure that the Relevant Client History is Open (eg, Mother, Father, Caregiver etc)

11. Document in the Notes of that Relevant Client History: Date referral made, Name of Referee, Brief referral reason, Attachment of

relevant documents/referral letter

12. Add Referral Follow-up Blue Alert Flag to Child &/or Relevant Client History


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Using Referral Letter Template for External Referral from Client (CHILD) Consultation

The Referral Letter template is not professionally sufficient to send as a referral in its current form – however it can be modified for use.

If using this Referral Letter template, the following details should be included:

Client Family details: Referrer details: Child date of birth Position Primary Caregiver name MCH Centre name Address Postal address Contact phone number Centre/Organisation phone number

Centre/Organisation email address

If printing this Referral Letter, it is ideal to print on the organisation letterhead.

The completed Referral Letter is automatically saved in the client’s history. (Letters/Reports – Correspondence History)

Hint - For a quick way of entering this information: 1. Create a word document with the following fields completed 2. Save 3. Copy (Ctrl + c) and Paste (Ctrl + v) into Referral Letter free-text field 4. Enter remaining information required

Child dob: Primary Caregiver: Address: Contact ph: -------------------------------------------------------------- Referrer details Position: MCH Centre name: Postal address: Centre/Organisation ph: Centre/Organisation email: --------------------------------------------------------------- Type letter here ……..


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Example of Completed External Referral in Client (CHILD) Consultation

In Client (CHILD) Consultation screen: Complete - displayed if Save was clicked on the External Referral pop-up box

This External Referral CANNOT be edited Only the Client Notes associated with this External Referral can be edited

via History/Notes – Notes

In Client (CHILD) Consultation screen: Draft - displayed if Save and continue was clicked on the External Referral pop-up box

This External Referral CAN be edited and completed via Clinical Activities – Referrals


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External Referral in Client (CHILD) Referral Screen – Editing & Completing

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1. In Client History, hover cursor over Clinical Activity

Move curser down and left click: Referrals

2. Click Open on relevant Referral to be edited/saved Incomplete Pending Referrals lists incomplete referrals Referral Status lists all complete referrals with their status as

either pending, active, completed or declined

3. Edit Select Referee if required – see Important Notes-Select Referee This is a mandatory field marked with *

4. Edit Reason from look-up list

More than one Reason can be selected Select one Reason at a time and click for each Reason can be deleted by clicking

5. Enter/edit Referral Letter (i.e., to be recorded in History/Notes)

6. Enter/edit Staff Member, Letter date & Attachments sent

7. Ensure informed consent to referral is received

Select by clicking Yes or No accordingly

8. Click Save No further editing

9. Completed referral displayed in Client Activity – Referrals

Referral Status lists completed referrals with their status as either pending, active, completed or declined

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Example of Completed External Referral in Client Notes Child History Relevant Client History – FATHER in this example


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Example of Completed External Referral in Client Notes – Editing External Referral Notes

1. In Client History, hover cursor over History/Notes

Move curser down and left click: Notes

2. Click Edit This will ONLY edit what is documented in the

Client Notes and NOT the External Referral

3. Add or edit Note

4. Select Edit reason Click either Incorrect Entry or Incomplete

Entry from look-up list

5. Click Save

Whilst there is the option to edit External Referral when in Client Notes – it ONLY edits the Notes and NOT the

actual Internal Referral itself

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Example of Completed External Referral Notes Edited in Client History/Notes

If External Referral Notes have been edited from Client Notes The Client Notes will then display the edited entry with the heading: Supersedes Progress note previous entered on [date of original] Additionally, the original Internal Referral Note will have the heading: Superseded by note entered on [date of edited version]

MAV MCH CDIS External Referral Process: Sept 2016 Referral Letters/Forms as Attachments to Client History Page 11 of 15

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1. In Client History, hover cursor over History/Notes

Move curser down and Left click: Attachments

2. Click Add Attachment

3. Click on either Electronic Upload or Physical Location Selection defaults to Electronic Upload

4. Enter Attachment description

5. Select Type, by clicking on Referral from look-up list Selection defaults to Electronic Upload

6. Click Browse…

7. Select relevant file by clicking on it, where the referral/form was saved It will then be displayed in File Name Best practice to save in personal drive Be sure to delete file in personal drive once attached

8. Click Open

9. The file is then displayed in File Name

10. Click Save

11. Referral is displayed

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Adding Referral Letters/Forms as Attachments to Client History

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MAV MCH CDIS External Referral Process: Sept 2016 Referral Letters/Forms as Attachments to Client History Page 12 of 15

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1. In Client History, hover cursor over History/Notes Move curser down and Left click: Attachments

2. Click Expand button

3. Click to view attachment details i. View attachment details & can open/save file

4. Click to download attachment i. Select Open or Save

5. Click to edit attachment details i. Edit File Name, Attachment description & Type

6. Click to delete attachment ONLY MANAGEMENT TO DELETE i. Delete attachment with Reason*

7. Example of attachment added & deleted in Client History Notes

Viewing, Editing & Deleting Attachments in Client History

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ONLY MANAGEMENT TO DELETE

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MAV MCH CDIS External Referral Process: Sept 2016 Adding ‘Referral Follow-up’ Blue Alert Flag for External Referrals Page 13 of 15

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Adding ‘Referral Follow-up’ Blue Alert Flag for External Referrals

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1. In Client History, hover cursor over Clinical Activity Move curser down and Left click: Flags/Alerts

2. Click Add to add Flag/Alert for referral follow-up

3. Select Category, by clicking on General from

look-up list

4. Select Details, by clicking on referral follow-up required from look-up list

5. Enter Start Date by using digits or calendar box

Defaults to today’s date

6. Enter Comments if relevant

7. Click Confirm

8. Blue Alert Flag is displayed in Client History

*Add new Flag/Alert for EVERY referral – repeat process*

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MAV MCH CDIS External Referral Process: Sept 2016 Status of External Referrals – Pending, Active, Completed or Declined Page 14 of 15

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Update Status of External Referrals - Pending, Active, Completed or Declined

Client Referrals Screen / Referral Status:

Pending – referred but not yet accepted/declined

Active – being currently actioned/receiving service

Completed – episode of care has ended/completed

Declined – referral declined

MAV MCH CDIS External Referral Process: Sept 2016 Referral Letters/Forms as Attachments in Client History Page 15 of 15

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Removing ‘Referral Follow-up’ Blue Alert Flag for External Referrals

‘Referral Follow-up’ Blue Alert Flags will need to be reviewed at each consultation (as the status of the referral is reviewed) and removed if required This is from both the Child History &/or relevant Client History

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1. In CHILD History, hover cursor over Clinical Activity Move curser down and left click: Flags/Alerts

2. Click Edit on relevant General: referral follow-up required Flag/Alert

3. Ensure Category & Details are correct: General: referral follow-up required This is auto filled

4. Enter End Date by using digits or calendar box

Calendar box displays red square around today’s date

5. Enter Comments if relevant For example, outcome and recommendations

6. Click Confirm

7. New display in Client History:

i. Blue Alert Flag Box with 1 less number or replaced with Light Blue Triangle ii. Status: Inactive displayed in CHILD Flags / Alerts

iii. End Date displayed in CHILD Flags / Alerts

**Repeat steps for Relevant Client History if appropriate**

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