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STANDARD OPERATING PROCEDURE
ADVANCED CARENOTES
Section 1
2
SOP Number
SOP Title Advanced CareNotes Standard Operating Procedure
Name Title Signature Date
Author Candice
Raymond
Sian Morgan
Heather
Anderson
Interim Health and
Therapies Manager
Therapy Assistant
Health and Therapies
Manager
Reviewer
Authoriser Joan Myers Associate Director for
Health Service and Chief
Nurse
April 2018
Effective Date: October 2017
Review Date: October 2018
PURPOSE
Introduction;
This Standard Operating Procedure provides a manual for use of the Advanced CareNotes electronic recording
system. Advanced CareNotes was introduced as the record keeping process for health staff in Achieving for
Children in November 2016. The purpose of this SOP, is to provide user guidelines on using the system in a
consistent way. Consistency and standardisation is important in order that information within the system is
logged in the appropriate places and we are able to run data reports which encapsulate all relevant
information.
This SOP covers use of CareNotes for clinical staff and does not describe reporting.
Specific terminology relating to the use of CareNotes is explained within the procedures outlined in this
document.
The document is relevant for all health staff using Advanced CareNotes for clinical record keeping, including
those who are not directly employed within AFC.
All staff must use the case notes and diary functions on Care Notes. There must not be separate AFC paper
notes for a child or young person.
Always input information onto one of the available forms on Care Notes if at all possible. This enables
reporting of the information contained in forms. If documents are scanned and uploaded it is not possible
to extract data from these documents.
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ADVANCED CARENOTES STANDARD OPERATING PROCEDURE CONTENTS
PURPOSE .............................................................................................................................................................................................. 2
USING THE SEARCH .............................................................................................................................................................................. 3
CREATING A NEW SPELL/REFERRAL ..................................................................................................................................................... 4
CREATING A NEW COMMUNITY EPISODE ........................................................................................................................................... 8
ITAC/EXTERNAL REFERRAL PROCESS ................................................................................................................................................. 11
ITAC SUMMARY FORM ............................................................................................................................................................... 11
ITAC MEETING PROCESS ............................................................................................................................................................. 13
FOLLOWING THE ITAC MEETING ................................................................................................................................................ 13
MAKING AN INTERNAL REFERRAL ..................................................................................................................................................... 13
ADDING A NEW PATIENT TO YOUR CASELOAD: ................................................................................................................................ 14
NOTE ........................................................................................................................................................................................... 16
HOW TO DISCHARGE A COMMUNITY EPISODE ................................................................................................................................. 17
HOW TO DISCHARGE A SPELL ............................................................................................................................................................ 19
USING THE SEARCH
The quickest way to find a child is often to search for them directly. Most people’s default page you see when opening ACN is the
search page. However if you have changed your settings or are on another screen you can return to or open the search page by
clicking the “Search” button at the top left side of the page.
When searching for children it is easier to use their DoB or NHS number if known as this is more likely to be unique. You can
either enter this in DD/MM/YYYY format or you can click on the calendar icon to the right of the box to get a calendar to navigate
through. If you don’t have their DoB to hand, you can use more than one box to search – for example if a child has a common
Forename and Surname, however it is usually not necessary and increases your chance for errors.
If you are unsure about the spelling of a child’s name or the name does not come up when you try to search for it you can use
‘wildcards’ which will search for anything in that space. For example searching for “dumm%” in the Forename box:
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Will bring up a child with “Dummy” or similar letters in their first name:
If you receive a no results return message either a mistake has been made or the CYP does not exist on system. After exhausting
your search options please contact the system administrator (Mia Upton @ YHC) to pull details from national data base. Please
provide them full details of child including Name, Surname, Date of Birth, Address and NHS number if available and they will set
this up on our behalf.
CREATING A NEW SPELL/REFERRAL
This is how to add a child who is on CareNotes but not under the Child Development Service or team caseload.
You have to open a referral or “Spell” to the Child Development Service (if one is not already open) before you can open a
“Community Episode” (which is the team caseload). All Community episodes for AfC ISCD teams need to be linked to the Child
Development Service for reporting purposes.
1. Search for Patient (see ‘Using the Search’) and open their ‘file’ by clicking on their name in the search list
2. Go to the patient’s page and go to the “Ref/Episodes”
3. Click on the “Create a new” box on the right hand side, then select “Referral”
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OR
1. Search for Patient (see ‘Using the Search’) this will bring up a search list. 2.
On the far right of their name click the “+” symbol
3. From the drop down list select referral
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Both options will then open the referral’s ‘Spell’ page:
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4. Fill in the form making sure to complete all boxes with a “*”. Note - for “Referral Source” you will either need to fill in
the “Staff” link or the “Referrer Address” section depending on where it came from.
a. Service: Child Development Service
b. Referral Date: Date the referral entered the building WITH consent
c. Received Date: Date the referral was input onto CareNotes (will always be today) d. Priority: Routine
e. Referral Source: Who the referral is from
f. Referral Reason: From drop down select “Assessment”
g. Referrer detail: Enter basic details for future reference such as address/ organisation name and referrers name/
job title.
h. Accepted Date: date accepted by the team (date stamped by Moor Lane reception if accepted at ITAC)
i. Start Date: date of initial appointment or advice given (note you do not have to fill out a start date if the referral
is on a waiting list and has not yet been seen – in this case the “Status” would be “1.Waiting”)
j. Accepted by: Referral coordinator name for ITAC
5. Click “Save” at the top
6. You now need to add the specific teams you wish to refer to (see “Creating a New Community Episode”)
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CREATING A NEW COMMUNITY EPISODE
This is how to add a child who is under the Child Development Service but not under a particular team (e.g. Nursing). If you are
making an internal referral please make sure you read the “Making an Internal Referral on CareNotes” section of this guide.
1. Search for Patient (see ‘Using the Search’) and open their ‘file’ by clicking on their name in the search list
2. Go to the patient’s page and go to the “Ref/Episodes”
3. Click on the “Create a new” box on the right hand side
OR
1. Search for Patient (see ‘Using the Search’) this will bring up a search list. 2.
On the far right of their name click the “+” symbol
4. Select “Community Episode ”
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3. From the drop down list select “Community Episode”
Both options will then open a “Community Episode” page:
5. Fill in the form making sure to complete all boxes with a “*”. Note - for “Referral Source” you will either need to fill in the
“Staff” link or the “Referrer Address” section depending on where it came from.
a. Service: always select Child Development Service
b. Team Location: This is the name of the team being referred/ opened to. For any new referrals into the service
this will be ITAC, once accepted from ITAC another community episode will be created with team accepted
c. Referral Date: Date the referral entered the building WITH consent
d. Received Date: Date the referral was input onto CareNotes (will always be today) e. Priority:
• Triage for ITAC
• Routine or urgent for other teams depending on pathway decision following ITAC CD
Commissioned for commissioned pieces of work.
g. Referral Source: Who the referral is from
• If internal (i.e. from someone else within the Child Development Service) the staff field will become
mandatory - complete this according to who referred internally
• If external fill out the “Referrer detail” section: Enter basic details for future reference such as address/
organisation name and referrers name/ job title.
h. Referral Reason: From drop down select ‘Assessment’
i. Status: Under status there are a number of options to use. Most of these are self-explanatory, however make
sure to use “Waiting” if an internal referral prior to ITAC. Below are two categories which can enable a team to
highlight priority cases and actions (to be used with agreement across whole teams). These are effectively a
means to flag cases for early attention:
• The “In Progress – Priority” highlighted below can be used by teams, when a child's case is 'in progress'
on your team caseload. This can be used to prioritise high need cases which need urgent action. Once
actions are completed the case should be moved back to “In Progress”
• The second is waiting priority which is only for cases currently in 'waiting' status (so yet to be allocated
or still going through the ITAC process etc). Again this allows teams to highlight cases which need
priority action, in order to support management of the waiting lists
j. Accepted Date: date accepted by the team (date stamped by Moor Lane reception for ITAC & Comm Paeds and
date of ITAC meeting for nurse/therapy teams)
k. Start Date: date of initial appointment or advice given (note you do not have to fill out a start date if the referral
is on a waiting list and has not yet been seen – in this case the “Status” would be “1.Waiting”)
l. Accepted by: Referral coordinator name for ITAC or the professional that accepted for team
m. Scroll to bottom of page and update waitlist for all teams to relevant pathway decided in ITAC - select “Waiting
List” and click on the relevant list - this need to be completed for all CYP to all teams where the CYP has not yet
been seen for an initial assessment (IA) or is awaiting their IA
n. Click the “Add” button. This will then include the waiting list in the “Selected Waiting Lists” at the bottom of the
page
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o. In the event that a referral is rejected due to there being no service available; status should be marked as
“rejected”. Under rejection details choose reason “not supported”. Under details add the service which is
unable to accept as there is no service available i.e OT, physio, nursing, paeds, EHS – please use these
abbreviations consistently to support future reporting.
6. Finally click “Save” at the top. If there are any unfilled required boxes an error will appear asking you to fill these out. Simply
fill in the box that was missed and click “Save” again.
7. Once you have seen a CYP you need to update the Community Episode form Administration section:
a. Open the community episode of the CYP and click “Edit” at the top of the page b.
Status: In Progress
c. Start Date: Date of initial appointment
d. Once you have done this remember to go to the team waitlist and remove CYP from waitlist
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ITAC/EXTERNAL REFERRAL PROCESS
Before the ITAC meeting, the referral coordinator receives referral, scans and uploads document onto CareNotes at the same
time as opening up a Spell to the Child Development Service if not currently open (see ‘Creating a New Spell/Referral’) and then
opens a Community Episode to the ITAC Team (see ‘Creating a New Community Episode’).
The following parameters on the page will need to be completed with the following information:
Referral Details
- Referral Date: Date on referral letter (date written)
- Received Date: Date referral received in building
- Priority: Routine
- Referral Source: As applicable
- Primary Referral Reason: Assessment
- Referrer Details: Name, designation and destination Administration:
- Episode Status: Waiting OR Spell Status: Accepted For Consideration
- Accepted Date: Same as received date
- Accepted By: Referral coordinators name
After this the referral coordinator will then open an ITAC Summary Form.
ITAC SUMMARY FORM
Health teams unable to attend ITAC meeting will be required to input their feedback on the ITAC Summary Form prior to the
meeting which will be viewed and discussed during the meeting.
1. Find the child and then access the ‘Ref/Episodes’ tab
2. Click ‘Create a new’ and select ‘CD AFC ITAC Summary Form v2’. Select the appropriate team.
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3. Fill in the referral date and next ITAC Meeting due date then click ‘Save’
4. At this point the name of the CYP should also be added to the rolling agenda for social care feedback to bring to next
ITAC meeting.
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ITAC MEETING PROCESS
Referral coordinator will share feedback given from various team members and update the ITAC Summary Form
with: - Details from discussion
- Issues identified (if accepted)
- Appointment Plan (if accepted)
- General Outcome
- Final ITAC Decision Date (leave blank if bring back required) Second Computer (ideally connected to projector
screen for all to view):
- Will open multiple ACN screens with all CYP referrals to be discussed during meeting
- Open and share notes/documents, alerts and community episodes should members of ITAC meeting request
further information to view and make decision
- Update community episode administration field for ITAC following decision to either:
- Pending Discharge (where a decision has been made to either accept or decline and coordinator has to finalise
paperwork) this will then request a start date which will be date of ITAC meeting
- Await further information (this is for referral where further information has been requested before a decision on
acceptance can be made and will be brought back for further discussion in ITAC follow receipt of this
information)
- Priority – if coordinator needs to prioritise action or outcome
- Once completed press ‘Save’
- For internal referral second computer will need to flag CD Internal Referrals outstanding on the ITAC Caseload
and be required to update the ITAC Community Episode by changing status to “Discharged”. Then the new
community episode for accepting team will be updated to “Accepted” with the date of the ITAC meeting for the
accepted date.
Complete details Click SAVE after completing details
FOLLOWING THE ITAC MEETING
The referral coordinator will update all external referrals with the appropriate team community episodes (see ‘Creating a New
Community Episode’). They will also issue a letter to parents (see ‘Creating a Letter’) which will inform them of the outcome
and give information regarding the process from them on.
MAKING AN INTERNAL REFERRAL
An informal discussion MUST be had with a colleague of the team you wish to refer to with the CYP accepted informally. The
referrer should make sure that the request meets the receiving team’s core criteria. Any supporting reports and documents
should be uploaded onto CareNotes BEFORE making the referral.
A community episode form will then need to be completed on CareNotes to the ITAC team (see “Creating a New Community
Episode”), completing mandatory fields only with the status “CD Internal”. At this point a parallel referral to the team being
referred to, should also be made with a status of “Waiting”. Add relevant case details in the episode comment box and you
must flag and upload all supporting documents. This is the referral on which to add any case discussion or detail in the
episode’s comments box. DO NOT use the status “Accepted” until the decision is formalised at ITAC.
Once this is done, open an ITAC summary form linked to the Child Development Service Spell (see ‘ITAC Summary Form’). An
email to referral coordinator (Gina Hook) informing her of the referral, should also be sent. All relevant information/
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documents (link to uploading documents) relating to the referral need to be uploaded at the same time and available for all to
open and read, additional information can be added to the ITAC summary form.
The referral coordinator will then add the name to the ITAC agenda for the following ITAC meeting and then circulate this as
usual. Discussion around internal referrals within ITAC meeting will be limited to a verbal ‘accepted’ unless another team
member feels they have relevant information which can add to the referral.
The referral acceptance will then be formalised in the following ITAC meeting and the community episode will then be
discharged from ITAC. The date of the ITAC meeting will be the accepted date for the team referral and the date from which
the 18 week wait time will be calculated for all teams except community paediatric which will work from the date that the
referral was opened to ITAC team.
When creating an internal referral episode please do not click on the “populate” from the referral box as all information
transferred in will be outdated.
ADDING A NEW PATIENT TO YOUR CASELOAD:
1. Go to the patient’s page and go to the “Ref/Episodes”
2. Click on the “Create a new” box on the right hand side and select “Team Member”
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-
OR
1. Search for Patient (see ‘Using the Search’) this will bring up a search list. 2.
On the far right of their name click the “+”symbol
3. From the list select “Team Member”
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3. Select the appropriate team from the list given. If your team is not there you will need to create a community episode
first (see “Creating a New Community Episode”)
4. To fill in the form:
a. “Start Date” put in the first date you pick up the child
b. “Name” is your name/name of the healthcare professional
c. “Role” is usually “Primary Worker” (all members of the team working with a CYP should be a “Primary
Worker” UNLESS they are the designated lead professional on a case - in this situation you would use “CDT
Key Worker”).
5. Click on “Save” at the top of the page – they should now be on your caseload
6. Once you finish seeing a child or transfer care to another member of the team you will need to discharge them from
your list. To do this simply edit the same Team Member and add an end date (the day you discharge them).
NOTE
If the CYP is already on somebody else’s caseload and you do this – it will not remove the child from their caseload, it will just
add you as well. You will need to discharge them to do this (see step 6).
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HOW TO DISCHARGE A COMMUNITY EPISODE
This is how to discharge a patient from a particular team’s caseload. If you are the only remaining AFC team working with that
child you will also need to discharge the Spell (see ‘How to Discharge a Spell’).
1. Before you discharge make sure to:
a. Update the Care Plan (see ‘CarePlans/Goals’) and outcome with evidence of reduced clinical risk. Make sure
to provide and “End Date” for the whole plan as well as any interventions outstanding
b. Upload a discharge report to documents if using and made a clinical note to this respect
2. Go to the patient’s page and go to the “Ref/Episodes”
3. Find and click on your team’s “COMMUNITY” episode in the list. This will open the Community Episode page
4. Click on “Edit” at the top
5. Then scroll down until you see the “Administration” section. Under “Status” choose “Discharged”.
6. Then fill in the section called “Discharge Details” with all the * fields filled in:
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a. Discharge Date: This is the date you discharged
b. Method use the following only:
- Activity Completed
- Declined Service
- Did not Attend
- Inappropriate Referral (for ITAC use only)
- Moved Out of Area
- Patient Died
- Team Transfer (ITAC or if moving to special school caseload, if you are referring to another team in
ISCD your teams option/ choice for discharge should be activity completed if all teams goals have been met)
c. Destination:
- Usual Place of residence (use for all regular discharges)
- Not Relevant (use if transferring internally within the ISCD)
- Patient Died
d. Closure Reason: Pick appropriate option
e. Agreed By: Me (or whichever HP has discharged)
7. Click “Save” at the top of the page.
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-
HOW TO DISCHARGE A SPELL
You will need to carry this out if you discharge a patient and they are the no longer under any other Child Development Teams.
Ensure all notes and documents to be uploaded have been completed before going through this step. Ensure discharge reason
shows evidence of reduction of clinical risk where this is the case.
1. Go to the patient’s page and go to the “Ref/Episodes”
2. Find and click on the “Spell” “Child Development Service” box
3. Click on “Edit” at the top of the page
4. Then scroll down until you see the “Administration” section. Under “Status” choose “Discharged”.
5. Then fill in the section called “Discharge Details” with all the * fields filled in:
a. Discharge Date: This is the date you discharged
b. Method use the following only:
- Activity Completed
- Declined Service
- Did not Attend
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- Inappropriate Referral (for ITAC use only)
- Moved Out of Area
- Patient Died
c. Destination:
- Usual Place of residence (use for all regular discharges)
- Patient Died
d. Closure Reason: Pick appropriate option
e. Agreed By: Me
6. Click “Save” at the top of the page.
