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Health Record Policy for Mental Health and Addiction Group 
MHAPPM/8046 
General Manager - Mental 
Approved by: 
First Issued:  March 2006 
Health & Addiction Group 
 
Review Date:  April 2022 
Signature: 
David Warrington 
Next Review:  April 2028 
Purpose 
The purpose of this document to describe and define the minimum documentation standards and 
requirements for Mental Health and Addiction Group. 
This document is to be used in conjunction with MHAPPM/8953 – Mental Health Service Policy which 
outlines the shared vision and expectations for the direction, values, principles, attitudes and ways of 
working to deliver a values based service. 
Scope 
All Mental Health and Addiction Group staff 
All Non-Government Organisations (NGO) who use the DHB’s patient management and clinical record 
systems i.e. ‘Electronic Clinical Application’ (ECA) and ‘Clinical Portal’. 
Definitions 
Refer to the Mental Health Service Definitions Glossary 
\\FS3\share\Public\All Users\MHS Policy review\DEFINITIONS FOR WORDS AND TERMS IN USE WITHIN THE 
MENTAL HEALTH SERVICE.docx. 
Roles and Responsibilities 
Role 
Responsibility 
Clinical Manager/General 
Ensure all staff are informed of the service documentation requirements and 
Manager/NGO Manager 
ensure compliance to this policy 
Triaging clinician 
Ensure completion of first contact/registration form, at the time of the first 
contact 
Commence the ‘Comprehensive Assessment’ 
Key Workers 
Are service providers who coordinate communications and activities for the 
Tangata whaiora in order to meet the goals described in their plan 
Ensure Tangata Whaiora’s documents/diagnoses/health records are 
accurately maintained, regularly reviewed, and are available to the right 
people at the right time so decision makers are properly informed 
Are the single or main point of contact for the Tangata Whaiora/family/ 
whānau, during service provision 
Ensure health records are completed within prescribed time limits and are 
available via the electronic patient management systems i.e. ‘Electronic 
Clinical Application’ and/or ‘Clinical Portal’ 
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Health Record Policy for Mental Health and Addiction Group 
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MHAPPM/8046 
Role 
Responsibility 
Key Workers (continued) 
Develop the plan in partnership with the person who is using the service and 
his/her support people, where possible. Update the plan as frequently as 
indicated in the Key Worker Procedure and as outlined in this policy (refer to 
sub-heading ‘Go to Plan’ below) 
Ensure all applicable Outcome Measures (Health of the Nation Outcome 
Scale and/or Alcohol, and Drug Outcome Measure) are collected as per the 
appropriate information collection protocol 
Where a staff member has been allocated the Key Worker responsibility but 
is not a registered health practitioner, a registered health practitioner must 
also be allocated to supervise the care given by the non-registered person 
i.e. the Key Worker. The Key Worker must have access to all clinical 
documentation to ensure that comprehensive assessment is completed and 
a Plan is developed and implemented 
Ensure the Tangata Whaiora’s Supplementary Consumer Records are kept 
continuously up to date 
Ensure the Tangata Whaiora’s ICD Code(s)/Diagnosis(es) are recorded as per 
points 25, 26 and 27 below. 
Mental Health Service 
Ensure health records are kept continuously up to date 
and Non-Governmental 
Organisation staff 
HBDHB Standards 

The Mental Health and Addictions Service recognises that the recovery of each person using the 
Mental Health and Addictions Service is dependent upon excellent clinical practice and that their 
health record must evidence comprehensive, organised information that reflects safe, efficient and 
effective practice 

Record keeping is essential in order to deliver safe and effective services that clearly identify the 
strengths and risks that may affect a person’s recovery. All people who are referred to mental health 
services must have the following forms completed and stored in their electronic health record: 
a. 
General Information Form 
b. 
Comprehensive Assessment 
c. 
Go To Plan 
d. 
Outcome measures: 
i) 
Health of the Nation Outcome Scale (HoNOS) 
ii)  Alcohol and other Drugs Outcome Measure (ADOM) 
e. 
ICD Code/Diagnosis(es) (International Classification of Diseases) 
i) 
This code (or multiple codes) must be recorded in the ‘Add/Change Diagnosis’ screen 
within the ‘Primary Referral’ 
f. 
Supplementary Consumer Records 
g. 
Discharge Summary Letter 

Dependant on the needs of individual, the completion of additional documentation may also be 
required, examples include, but are not limited to:- Clinical Risk Assessment forms, (refer to 
MHAPPM/8102 - Clinical Risk Management System (CRMS) Procedure and/or Mental Health Act 
Forms (refer to HBDHB/CPG/073 - Mental Health Act (1992) Initiating Urgent Compulsory 
Assessment 
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Health Record Policy for Mental Health and Addiction Group 
April 2022 
MHAPPM/8046 

Each document must be completed and (where applicable) reviewed (using ‘Portal Forms’ within 
‘Clinical Portal’) within the following described time limits. 
First Contact and Registration Form 

To be completed by the end of the clinicians’ duty, following the first face to face contact 

The information contained in this document is to be transferred into the person’s health record in 
ECA 

Once the information is viewable via ECA, then any paper version can be destroyed 
General Information Form 

To be completed by the end of the clinicians’ duty, following the first face to face contact 

This document is to be viewable via the person’s NHI number in ECA (may need to be scanned and 
saved) 
Comprehensive Assessment 
10 
To be completed by the registered health care practitioner: 
a. 
Inpatients : within 24 Hours or  
b. 
Community patients : within the first three face to face contacts (or two weeks – whichever is 
sooner 
11 
This document is to be kept continuously up to date 
12 
The Key Worker must review this document at least once every three months (in collaboration with 
the person where possible) and make an entry into the clinical notes to evidence that it has been 
reviewed 
13 
This form is to be viewable via the person’s NHI number in ‘Clinical Portal’ 
14 
Once the document is viewable via ‘Clinical Portal’ then any paper version can be destroyed 
The ‘Go To Plan’ 
15 
Community: 
a. 
The ‘Go To Plan’ must be documented within the first three contacts (including any type of 
contact) and reviewed at least once every three months thereafter or as circumstances change 
16 
Inpatients: 
a. 
The ‘Go To Plan’ must be documented within 24 hours and reviewed at least every day 
thereafter 
17 
The ‘Go To Plan’ must be updated during the two weeks prior to closing the Primary referral and 
must include the plan for transiting from Mental Health and Addiction Services to the care of their 
General Practitioner 
18 
This document is to be viewable via the person’s NHI number in ‘Clinical Portal’ 
Health of the Nation Outcome Scale (HoNOS/HoNOSCA/HoNOS 65+) 
19 
To be completed according to the ‘Information Collection Protocol’ 
20 
To be completed in the electronic patient management system (i.e. ‘ECA’) 
 
 
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Health Record Policy for Mental Health and Addiction Group 
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MHAPPM/8046 
Alcohol & Drug Outcome Measure (ADOM) 
21 
To be completed following the 2nd face to face encounter with an ‘Addiction’ type case team 
22 
To be completed according to the ‘Guide for Addiction Practitioners’ 
23 
To be completed in the electronic patient management system (i.e. ‘ECA’) 
Supplementary Consumer Records 
24 
The Key worker must keep these records continuously up to date and update these records as and 
when changes occur 
ICD Code/Diagnosis(es) 
25 
A minimum of one ICD code must be recorded in the ‘Add/Change Diagnosis’ fields by the end of the 
shift during which the assessment took place 
26 
Up to six ICD codes/diagnoses can be recorded simultaneously within the ‘Add/Change Diagnosis’ 
fields contained within the ‘Primary referral’ 
n.b. also include all physical disorders when recording ICD codes/Diagnosis(es) 
27 
The person’s diagnosis(es) must be kept continuously up to date as and when changes occur 
Discharge Summary Letter 
28 
It is a requirement that each person referred back to Primary Care at the end of their mental health 
and/or addictions treatment receive a discharge summary letter to be handed to or mailed to the 
person prior to closing the Primary referral 
29 
The letter must also be copied to the person’s General Practitioner. The summary letter should 
include ongoing arrangements, how to regain entry to the service and who to contact at a later date 
if required. (Refer NZS 8134:2021 Section 3.6 “Transition, transfer and discharge”). 
30 
Consideration must also be given to informing the initial referrer 
31 
All documents must be updated as information and/or the situation changes 
Measurable Outcomes 
Health Records will be audited annually. 
Audit results will routinely be made available to clinicians within four weeks of audit completion. 
Health record audit results will inform continuous improvement. 
Related Documents 
MHAPPM/8953 – Mental Health Service Policy 
HBDHB/OPM/033 - Privacy Policy 
HBDHB/OPM/074 - Health Record Policy  
HBDHB/OPM/075 - Health Record Policy - Storage Security Accessibility and Off Site Storage 
Health Practitioner’s Competence Assurance Act 2003 
Privacy Act 2020 
Health Information Privacy Code 2020 
Health & Disability Commissioner (Code of Health & Disability Services Consumers’ Rights) Regulation 1996 
HoNOS family of measures | Using Measures to Enhance Outcomes | Te Pou 
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Health Record Policy for Mental Health and Addiction Group 
April 2022 
MHAPPM/8046 
References 
New Zealand Standard: Health Records 8153: 2002  
HoNOS family of measures | Using Measures to Enhance Outcomes | Te Pou 
Alcohol & Drug Outcome Measure (ADOM) - Guide for Addiction Practitioners 
'Health and Disability Services Standard 8134-2021’ 
International Classification of Diseases – World Health Organisation 
Keywords 
Records 
Record-keeping 
Documentation 
File 
For further information please contact the  
Quality Systems Manager - Mental Health and Addiction Group 
Hawke’s Bay District Health Board 
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