The entry process to the MHS meets the needs of its community and facilitates timeliness of entry and ongoing assessment.

Suggested evidence


The intent of this Standard is to ensure that entry processes to the mental health service (MHS) are made known to the community it serves and that entry processes are efficient.

Documented entry policy and process (Criterion 10.3.1)

The MHS should have a documented entry policy and procedure which includes:
  • the system of on call, entry and assessment

  • how to ensure the needs of Aboriginal and Torres Strait Islander persons, culturally and linguistically diverse (CALD) persons are met and that religious and spiritual beliefs, gender, sexual orientation, physical and intellectual disability, age and socio-economic status are addressed in the entry process

  • the use of interpreters

  • assessing the specific needs of the consumer in terms of the type of services required

  • the process of making alternative arrangements and a smooth transition of care to a more appropriate MHS if the MHS accessed cannot provide this service.

Provision of information on the entry process (Criterion 10.3.2)

The MHS should have a procedure for disseminating information on the entry process to consumers, carers, and other service providers. This can be done through such activities as mail outs of posters and brochures, providing online information, interagency liaison and regular liaison with referral sources.

Posters and brochures that provide information on the entry process should be prominently displayed in every facility of the MHS and also made available on the MHS website and via email, fax or post on request.Top of page

Prioritisation of referrals (Criterion 10.3.3)

Prioritisation of referrals varies, depending on the service and the sector. The MHS can routinely monitor its 'non-accepted' referrals and review procedures where necessary.

The MHS needs to be able to formally identify who is responsible for monitoring and evaluating compliance with entry policies and procedures.

Defined pathway for entry into the MHS (Criterion 10.3.4)

The MHS should have one entry point for each service it delivers.

For mental health services that have multiple sites, the system of on call, entry and assessment needs to be coordinated by the appropriate staff or governing body.

Minimise delay and duplication (Criterion 10.3.5)

The MHS should be able to provide evidence that the individual consumer health record and treatment, care and recovery plan was started when the consumer entered the service. The means of entry to the service should be recorded in the consumer's health record.

The MHS contacts health professionals involved in earlier episodes of care to obtain relevant information as soon as practicable after the consumer enters the MHS. Evidence that the MHS attempted to obtain information on any earlier episodes of care should be documented in the consumer's individual health record.

Wherever possible the MHS should access the consumer's previous health record to eliminate duplication.

Involuntary admission (Criteria 10.3.6, 10.3.7)

For some consumers, voluntary or involuntary status can change within the same admission period to an inpatient facility. The MHS should have protocols available that encourage voluntary status where this does not pose a risk to the consumer, carer, visitors or staff.

The MHS should offer counselling and debriefing for consumers and carers who are admitted as involuntary patients.

Providing a counselling and debriefing service to consumers and carers may not always be appropriate during the admission stage but it is imperative that this occurs during the period of care.

The MHS and relevant evacuation agencies operating in rural and remote settings (such as police, ambulance or the Royal Flying Doctor Service) should ensure they have clear guidelines consistent with the relevant legislation. Whenever involuntary evacuation of a consumer is undertaken carers and other relevant community members should be engaged as early in the process as possible to ensure understanding and cooperation. Feedback to this group should also be guaranteed.

Care management on entry (Criterion 10.3.8)

On entry to the MHS an interim or permanent person responsible for the coordination of care is appointed to the consumer. The consumer and the carer should be advised of who this person is and any changes should be made known to the consumer and the carer.

The MHS must ensure that in Indigenous settings where there are no resident MH practitioners, there is an identified person (usually within the primary care centre) and a process to ensure that all case management issues and decisions can be directly and appropriately conveyed to consumers and carers.Top of page

Suggested evidence

Evidence that may be provided for this standard includes:
  • information on entry criteria
  • evidence of dissemination of information
  • posters and brochures
  • a health record review, including referrals and previous treatment
  • evidence of coordination with other sites
  • treatment, care and recovery plans
  • policies and procedures covering:
    • the referral process
    • triage
    • the entry process, including inclusion and exclusion criteria
    • safe transport
    • evacuation protocols
    • mechanisms for review.