Admission to community follow-up, one continuous flow

Referral documented with source, presenting need, and initial eligibility assessment.

System: Referral record created and assigned to admissions coordinator.

Clinical assessment completed and recorded against the referral. Outcome and recommendation documented.

System: Assessment form attached to referral. Status updated to Assessment Complete.

Placement decision approved. Unit and room assigned. Admission date set.

System: Resident record created. Unit occupancy updated. Admission date confirmed.

All required admission documentation completed and signed — consent, care agreement, personal profile.

System: Admission forms marked complete. Care programme initialised.

Initial care plan drafted, reviewed with resident, and formally activated.

System: Care programme status set to Active. First review date scheduled automatically.

A structured HSE-aligned assessment is scheduled against the resident’s record, with the relevant form template attached.

System: Assessment form instance created and linked to resident record.

Clinician completes the assessment digitally, using assisted dictation where useful, with mandatory fields validated before submission.

System: Form validated, signed, and version locked against the resident record.

Resident status, unit assignment and care team are set from the confirmed admission, becoming the single reference point for the stay.

System: Resident record status set to Active. Care team notified.

Status changes, flags and legal/consent updates are recorded against the resident as they occur, not batched for later.

System: Resident record updated in real time. Change history retained.

Staff review occupancy, admissions and the day’s scheduled activities at shift handover.

System: Timeline dashboard refreshed with live occupancy and schedule data.

Activities, appointments and roll calls proceed against the schedule, with missed items flagged automatically.

System: Activity outcomes logged. Missed-event alerts dispatched to assigned staff.

Facilitator runs the scheduled group session using structured discussion prompts and a session timer.

System: Session record created with module, timer and participant list.

Observations and quick comments are captured by tapping pre-built terms during the session, then reviewed into categorised notes.

System: Structured note lines generated per resident from tapped terms.

Staff member records the incident immediately or as soon as practicable after the event.

System: Incident record created with timestamp. Notifications dispatched to designated persons.

Person in charge reviews and formally acknowledges the incident report.

System: Acknowledgement logged. Escalation flag set if severity threshold met.

Investigation assigned to the appropriate person with expected completion date.

System: Investigation record created and linked to incident. Due date reminder scheduled.

Investigation findings, root cause analysis, and corrective actions documented with assigned owners.

System: Corrective actions created with assigned owner and due dates. Overdue alerts configured.

All corrective actions verified complete. Incident record closed with sign-off.

System: Incident status set to Closed. Full record locked. Audit trail preserved.

Scheduled care plan review compares current status against the goals set at admission, with multi-disciplinary input.

System: Review outcome recorded. Next review date scheduled automatically.

Managers review resident and unit-level trends drawn directly from operational data ahead of team meetings.

System: Report generated from live operational data, no manual collation required.

Discharge is planned against the resident’s progress, with aftercare and community handover requirements identified.

System: Discharge record created. Aftercare checklist generated.

Discharge is confirmed, unit occupancy updated, and the resident record locked to its final residential state.

System: Resident status set to Discharged. Unit occupancy updated. Record retained for audit.

Where relevant, the same service-user record continues into community-based support rather than starting again.

System: Record linked to Community Services module. Practitioner assigned.

Community practitioners continue appointments, outreach visits and periodic review against the same continuous record.

System: Outreach visits and appointments logged against the continued record.