Mental Health FHIR Store Mappings: Difference between revisions

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The Discovery Collaborative commissioned the creation of an expanded set of data ingestion specifications and to work to agree these specifications as Standards for how data will be received and ingested into the Discovery Data Service (“DDS”) in future projects. The expanded data specifications focused on multiple healthcare areas, with one of those being Mental Health. Others include; Social Care, Community, and Acute.
== MHSDS ==
 
The Mental Health Service Data Set (MHSDS) brings together information captured on clinical systems as part of patient care. It covers not only services provided in hospitals but also outpatient clinics and in the community, where the majority of people in contact with these services are treated.
 
The MHSDS is a patient level, output based, secondary uses data set which aims to deliver robust, comprehensive, nationally consistent and comparable person-based information for children, young people and adults who are in contact with services for mental health and wellbeing, Learning Disability, autism or other neurodevelopmental conditions.
 
You can find the expanded data specification for the MHSDS outlined below.
 
== Patient Demographics ==
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!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|LOCAL  PATIENT IDENTIFIER (EXTENDED)
|LOCAL  PATIENT IDENTIFIER (EXTENDED)
Line 195: Line 187:
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
| GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
| GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
Line 218: Line 210:
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|ACCOMMODATION TYPE
|ACCOMMODATION TYPE
Line 306: Line 298:
!Description
!Description
! Conformance
! Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
| EMPLOYMENT STATUS
| EMPLOYMENT STATUS
Line 367: Line 359:
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
|CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
|An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing.
|An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing.
|R
|R
|
|Y - Yes: PATIENT requires constant care and/or supervision
 
 
N - No: PATIENT does not require constant care and/or supervision
|-
|-
| PARENTAL RESPONSIBILITIES INDICATOR
| PARENTAL RESPONSIBILITIES INDICATOR
|An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT.
|An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT.
|R
|R
|
|Y - Yes: PATIENT has parental responsibilities for a child or young person
 
 
N - No: PATIENT does not have parental responsibilities for a child or young person
 
 
Z - Not Stated (PATIENT asked but declined to provide a response)
 
 
X - Not Known (not recorded)
|-
|-
|YOUNG CARER INDICATOR
|YOUNG CARER INDICATOR
| An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling.
| An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling.
|R
|R
|
|Y - Yes: PATIENT has a caring role for an ill or disabled parent, Carer or sibling
 
 
N - No: PATIENT does not have a caring role for an ill or disabled parent, Carer or sibling
 
 
Z.- Not Stated: (PATIENT asked but declined to provide a response)
 
 
X.- Not known whether the PATIENT is a young Carer
|-
|-
|LOOKED AFTER CHILD INDICATOR
|LOOKED AFTER CHILD INDICATOR
|An indication of whether a PATIENT is a Looked After Child.
|An indication of whether a PATIENT is a Looked After Child.
|R
|R
|
|Yes - is a Looked After Child
 
 
No - is not a Looked After Child
 
Not Known if the PATIENT is a Looked After Child
|-
|-
|LOOKED AFTER CHILD LEGAL STATUS
|LOOKED AFTER CHILD LEGAL STATUS
|The legal status of the Looked After Child. This refers to the Children's Act 1989: see details <nowiki>https://www.legislation.gov.uk/ukpga/1989/41/contents</nowiki>
|The legal status of the Looked After Child. This refers to the Children's Act 1989: see details <nowiki>https://www.legislation.gov.uk/ukpga/1989/41/contents</nowiki>
|R
|R
|
|01 - Section 20 Voluntary Agreement
 
 
02 = Section 31 Care Order
 
 
03 = Section 38 Interim Care Order
 
 
08 = Other (not listed)
|-
|-
|EDUCATIONAL ASSESSMENT OUTCOME
|EDUCATIONAL ASSESSMENT OUTCOME
| The outcome of an EDUCATIONAL ASSESSMENT.
| The outcome of an EDUCATIONAL ASSESSMENT.
|R
|R
|
|01 - No Special Education Needs
 
05 - Subject to Education, Health and Care Plan (EHC)
|-
|-
|CHILD PROTECTION PLAN INDICATION CODE
|CHILD PROTECTION PLAN INDICATION CODE
|An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan.
|An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan.
|R
|R
|
|1 - Has never been subject to a Child Protection Plan
 
2 - Has previously been subject to a Child Protection Plan
 
3 - Is currently subject to a Child Protection Plan
 
X - Not Known whether the PATIENT is or has ever been the subject of a Child Protection Plan
|-
|-
|EX-BRITISH ARMED FORCES INDICATOR
|EX-BRITISH ARMED FORCES INDICATOR
|An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member.
|An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member.
|R
|R
|
|02 - Ex-services member
 
03 - Not an ex-services member or their dependant
 
05 - Dependant of an ex-services member
 
UU - Unknown (PATIENT asked and does not know or is not sure)
 
ZZ - Not stated (PATIENT asked but declined to provide a response)
|-
|-
|OFFENCE HISTORY INDICATION CODE
|OFFENCE HISTORY INDICATION CODE
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This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information.
This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information.
|R
|R
|
|1 - No - No offence
 
2 - Yes - Less serious offence
 
3 - Yes - Serious offence
 
X - Not Known (Not Recorded)
|-
|-
|PRODROME PSYCHOSIS DATE
|PRODROME PSYCHOSIS DATE
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|An indicator to alert the clinician that this patient may need a reasonable adjustment made
|An indicator to alert the clinician that this patient may need a reasonable adjustment made
|R
|R
|
|Y - Yes - the patient requires a Reasonable Adjustment
 
N - No - the patient does not require a Reasonable Adjustment
|}<br />
|}<br />


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!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
|START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
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|The type of service or team the Care Professional is associated with.
|The type of service or team the Care Professional is associated with.
|R
|R
|
|A01 Day Care Service
|}<br />
 
A02 Crisis Resolution Team/Home Treatment Service


=== DisabilityType ===
A05 Primary Care Mental Health Service
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
| DISABILITY CODE
| The DISABILITY of a PERSON.


This could be where:
A06 Community Mental Health Team - Functional


the PERSON has been diagnosed as disabled or
A07 Community Mental Health Team - Organic


the PERSON considers themself to be disabled.
A08 Assertive Outreach Team
|M
|
|-
| DISABILITY IMPACT PERCEPTION
|The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months.
|R
|
|}<br />


=== Care Plan Type ===
A09 Community Rehabilitation Service
{| class="wikitable"
 
!Name
A10 General Psychiatry Service
!Description
 
!Conformance
A11 Psychiatric Liaison Service
!Value Set
|-
| CARE PLAN IDENTIFIER
| A unique identifierfor Care Plan.
|M
|
|-
|CARE PLAN TYPE (MENTAL HEALTH)
|The type of Care Plan for the patient, recorded by the service.
|M
|
|-
|CARE PLAN CREATION DATE
|The date that a Care Plan was created for a patient.
|M
|
|-
|CARE PLAN CREATION TIME
|The time that a Care Plan was created for a patient.
|R
|
|-
|CARE PLAN LAST UPDATED DATE
|The date that the Care Plan was last updated for a patient.


Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date.
A12 Psychotherapy Service
|R
|
|-
|CARE PLAN LAST UPDATED TIME
|The time that the Care Plan was last updated for a patient.


Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time.
A13 Psychological Therapy Service (non IAPT)
|R
 
|
A14 Early Intervention Team for Psychosis
|-
 
| CARE PLAN IMPLEMENTATION DATE
A15 Young Onset Dementia Team
|The date that the Care Plan was implemented for a patient.
 
|R
A16 Personality Disorder Service
|
 
|}<br />
A17 Memory Services/Clinic/Drop in service
 
A18 Single Point of Access Service
 
A19 24/7 Crisis Response Line
 
A20 Health Based Place Of Safety Service


=== Care Plan Agreement ===
A21 Crisis Café/Safe Haven/Sanctuary Service
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|FAMILY INVOLVED IN CARE PLAN INDICATOR
|An indication of whether a member of the patient's family is currently involved in the patient's care plan.


This only needs to be captured for inpatients that are in scope of Transforming Care.
A22 Walk-in Crisis Assessment Unit Service
|R
|
|-
|FAMILY NOT INVOLVED IN CARE PLAN REASON
|The reason that the patient's family is not currently involved in the patient's care plan.


This only needs to be captured for inpatients that are in scope of Transforming Care.
A23 Psychiatric Decision Unit Service
|R
 
|
A24 Acute Day Service
|-
 
|CARE PLAN CONTENT AGREED BY
A25 Crisis House Service
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT.
 
|M
B01 Forensic Mental Health Service
|
 
|-
B02 Forensic Learning Disability Service
|CARE PLAN CONTENT AGREED DATE
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy.
|R
|
|-
|CARE PLAN CONTENT AGREED TIME
| The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy
|R
|
|}<br />


=== Assistive Technology to Support Disability Type ===
C01 Autism Service
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
|The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on.
|M
|
|-
|PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY)
|The date, time and time zone for the prescription of Assistive Technology.
|R
|
|}<br />


=== Social and Personal Circumstances ===
C02 Specialist Perinatal Mental Health Community Service
{| class="wikitable"
 
!Name
C04 Neurodevelopment Team
!Description
 
C05 Paediatric Liaison Service
 
C06 Looked After Children Service
 
C07 Youth Offending Service
 
C08 Acquired Brain Injury Service
 
C10 Community Eating Disorder Service
 
D01 Substance Misuse Team
 
D02 Criminal Justice Liaison and Diversion Service
 
D03 Prison Psychiatric Inreach Service
 
D04 Asylum Service
 
D05 Individual Placement and Support Service
 
D06 Mental Health In Education Service
 
D07 Problem Gambling Service
 
D08 Rough Sleeping Service
 
E01 Community Team for Learning Disabilities
 
E02 Epilepsy/Neurological Service
 
E03 Specialist Parenting Service
 
E04 Enhanced/Intensive Support Service
 
F01 Mental Health Support Team
 
F02 Maternal Mental Health Service
 
F03 Mental Health Services for Deaf people
 
F04 Veterans Complex Treatment Service
 
F05 Enhanced care in care homes teams
 
F06 Mental Health and Wellbeing Hubs
 
Z01 Other Mental Health Service - in scope of National Tariff Payment System
 
Z02 Other Mental Health Service - out of scope of National Tariff Payment System
|}<br />
 
=== DisabilityType ===
{| class="wikitable"
!Name
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
| DISABILITY CODE
|The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person.
| The DISABILITY of a PERSON.
|M
 
|
This could be where:
 
the PERSON has been diagnosed as disabled or
 
the PERSON considers themself to be disabled.
|M
|01 Behaviour and Emotional
 
02 Hearing
 
03 Manual Dexterity
 
04 Memory or ability to concentrate, learn or understand (Learning Disability)
 
05 Mobility and Gross Motor
 
06 Perception of Physical Danger
 
07 Personal, Self Care and Continence
 
08 Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
 
09 Sight
 
10 Speech
 
XX Other (not listed)
 
NN No Disability
 
ZZ Not Stated (Person asked but declined to provide a response)
|-
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP
| DISABILITY IMPACT PERCEPTION
|The date, time and time zone on which the Social and Personal Circumstance was recorded.
|The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months.
|R
|R
|
|01 - Yes – limited a lot
 
02 - Yes – limited a little
 
03 - No - not limited
 
04 - Prefer not to say (Patient asked but declined to provide a response)
|}<br />
|}<br />


=== Overseas Visitor Charging Category ===
=== Care Plan Type ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|OVERSEAS VISITOR CHARGING CATEGORY
| CARE PLAN IDENTIFIER
|The charging category relating to an OVERSEAS VISITOR STATUS.
| A unique identifierfor Care Plan.
|M
|M
|
|
|-
|-
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE
|CARE PLAN TYPE (MENTAL HEALTH)
|The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded.
|The type of Care Plan for the patient, recorded by the service.
|M
|10 - Mental Health Care Plan
 
11 - Urgent and Emergency Mental Health Care Plan
 
12 - Mental Health Crisis Plan
 
13 - Positive Behaviour Support Plan
 
14 - Child or Young Person's Mental Health Transition Plan
|-
|CARE PLAN CREATION DATE
|The date that a Care Plan was created for a patient.
|M
|
|-
|CARE PLAN CREATION TIME
|The time that a Care Plan was created for a patient.
|R
|
|-
|CARE PLAN LAST UPDATED DATE
|The date that the Care Plan was last updated for a patient.
 
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date.
|R
|
|-
|CARE PLAN LAST UPDATED TIME
|The time that the Care Plan was last updated for a patient.
 
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time.
|R
|R
|
|
|-
|-
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE
| CARE PLAN IMPLEMENTATION DATE
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until.
|The date that the Care Plan was implemented for a patient.
|R
|R
|
|
|}<br />
|}<br />


=== Mental Health Currency Model ===
=== Care Plan Agreement ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT)
|FAMILY INVOLVED IN CARE PLAN INDICATOR
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type.
|An indication of whether a member of the patient's family is currently involved in the patient's care plan.
|P
 
|
This only needs to be captured for inpatients that are in scope of Transforming Care.
|R
|Y - Yes - a member of the patient's family is currently involved in the patient's care plan
 
N - No - a member of the patient's family is not currently involved in the patient's care plan
 
9 - Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN
|-
|-
|START DATE (MENTAL HEALTH RESOURCE GROUP)
|FAMILY NOT INVOLVED IN CARE PLAN REASON
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group
|The reason that the patient's family is not currently involved in the patient's care plan.
|P
 
|
This only needs to be captured for inpatients that are in scope of Transforming Care.
|R
|01 - At the request of the patient
 
02 - Access restrictions on the family
 
03 - No known family
 
08 - Other (not listed)
|-
|-
|END DATE (MENTAL HEALTH RESOURCE GROUP)
|CARE PLAN CONTENT AGREED BY
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service.
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT.
|P
|M
|
|Patient or Patient Proxy
|}<br />
 
Advocate


=== Service or Team Referral ===
Clinical Service or Team
{| class="wikitable"
 
!Name
Local Community Support Team
!Description
 
!Conformance
Commissioner
!Value Set
 
Family member or carer with parental responsibility
 
Family member or carer without parental responsibility
|-
|-
|SERVICE REQUEST IDENTIFIER
|CARE PLAN CONTENT AGREED DATE
|The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned.
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy.
|M
|R
|
|10 - Patient or Patient Proxy
 
12 - Advocate
 
13 - Clinical Service or Team
 
14 - Local Community Support Team
 
15 - Commissioner
 
16 - Family member or carer with parental responsibility
 
17 - Family member or carer without parental responsibility
|-
|-
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
|CARE PLAN CONTENT AGREED TIME
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care.
| The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy
|M
|R
|
|
|}<br />
=== Assistive Technology to Support Disability Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|REFERRAL REQUEST RECEIVED DATE
|ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
|This is the date the REFERRAL REQUEST was received by the Health Care Provider.
|The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on.
|M
|M
|
|
|-
|-
|REFERRAL REQUEST RECEIVED TIME
|PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY)
|This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care.
|The date, time and time zone for the prescription of Assistive Technology.
|R
|R
|
|
|}<br />
=== Social and Personal Circumstances ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|NHS SERVICE AGREEMENT LINE NUMBER
|SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
|A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES.
|The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person.
|R
|M
|
|
|-
|-
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP
|The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements.
|The date, time and time zone on which the Social and Personal Circumstance was recorded.
|R
|R
|
|
|}<br />
=== Overseas Visitor Charging Category ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET
|OVERSEAS VISITOR CHARGING CATEGORY
|The source of referral to a Mental Health Service.
|The charging category relating to an OVERSEAS VISITOR STATUS.
|R
|M
|
|A - Standard NHS-funded PATIENT
 
B - Immigration Health Surcharge payee
 
C - Charge-exempt Overseas Visitor (European Economic Area)
 
D - Chargeable European Economic Area PATIENT
 
E - Charge-exempt Overseas Visitor (non-European Economic Area)
 
F - Chargeable non-European Economic Area PATIENT
 
P - Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY
 
9 - OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded)
|-
|-
|ORGANISATION IDENTIFIER (REFERRING)
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust.
|The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded.
|R
|R
|
|
|-
|-
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE
|The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer.
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until.
|R
|R
|
|
|}<br />
=== Mental Health Currency Model ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|CLINICAL RESPONSE PRIORITY TYPE
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT)
|The clinical response priority of a SERVICE REQUEST.
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type.
|R
|P
|
|
|-
|-
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
|START DATE (MENTAL HEALTH RESOURCE GROUP)
|This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group
|R
|P
|
|
|-
|-
|REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH)
|END DATE (MENTAL HEALTH RESOURCE GROUP)
|The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES.
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service.
|R
|P
|
|
|}<br />
=== Service or Team Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT)
|SERVICE REQUEST IDENTIFIER
|The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned.
|R
|M
|
|
|-
|-
|DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT)
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
|The time that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care.
|R
|M
|
|
|-
|-
|DISCHARGE PLAN CREATION DATE
|REFERRAL REQUEST RECEIVED DATE
|The date that a Discharge Plan was created for a patient.
|This is the date the REFERRAL REQUEST was received by the Health Care Provider.
|R
|M
|
|
|-
|-
|DISCHARGE PLAN CREATION TIME
|REFERRAL REQUEST RECEIVED TIME
|The time that a Discharge Plan was created for a patient.
|This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care.
|R
|R
|
|
|-
|-
|DISCHARGE PLAN LAST UPDATED DATE
|NHS SERVICE AGREEMENT LINE NUMBER
|The date that the Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Date.
|A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES.
|R
|R
|
|
|-
|-
|DISCHARGE PLAN LAST UPDATED TIME
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
|The time that a Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Time.
|The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements.
|R
|R
|
|
|-
|-
|SERVICE DISCHARGE DATE
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET
|Service Discharge Date is the date a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
|The source of referral to a Mental Health Service.
|R
|R
|
|A1 - Primary Health Care: General Medical Practitioner Practice
|-
 
|SERVICE DISCHARGE TIME
A2 - Primary Health Care: Health Visitor
|Service Discharge Time is the time a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
 
|R
A3 - Other Primary Health Care
|
 
|}<br />
A4 - Primary Health Care: Maternity Service
 
B1 - Self-Referral: Self
 
B2 - Self-Referral: Carer/Relative
 
C1 - Local Authority and Other Public Services: Social Services


=== Other Reason for Referral ===
C2 - Local Authority and Other Public Services: Education Service / Educational Establishment
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|OTHER REASON FOR REFERRAL (MENTAL HEALTH)
|The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service.
|M
|
|}<br />


=== Service or Team Type Referred To ===
C3 - Local Authority and Other Public Services: Housing Service
{| class="wikitable"
 
!Name
D1 - Employer
!Description
 
!Conformance
D2 - Employer: Occupational Health
!Value Set
 
E1 - Justice System: Police
 
E2 - Justice System: Courts
 
E3 - Justice System: Probation Service
 
E4 - Justice System: Prison
 
E5 - Justice System: Court Liaison and Diversion Service
 
E6 - Justice System: Youth Offending Team
 
F1 - Child Health: School Nurse
 
F2 - Child Health: Hospital-based Paediatrics
 
F3 - Child Health: Community-based Paediatrics
 
G1 - Independent sector - Medium Secure Inpatients
 
G2 - Independent Sector - Low Secure Inpatients
 
G3 - Other Independent Sector Mental Health Services
 
G4 - Voluntary Sector
 
H1 - Acute Secondary Care: Emergency Care Department
 
H2 - Other secondary care specialty
 
I1 - Temporary transfer from another Mental Health NHS Trust
 
I2 - Permanent transfer from another Mental Health NHS Trust
 
M1 - Other: Asylum Services
 
M2 - Other: Telephone or Electronic Access Service
 
M3 - Other: Out of Area Agency
 
M4 - Other: Drug Action Team / Drug Misuse Agency
 
M5 - Other: Jobcentre Plus
 
M6 - Other SERVICE or agency
 
M7 - Other: Single Point of Access Service
 
M9 - Other: Urgent and Emergency Care Ambulance Service
 
N3 - Improving Access to Psychological Therapies Service
 
P1 - Internal Referral
 
Q1 - Mental Health Drop In Service
|-
|-
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|ORGANISATION IDENTIFIER (REFERRING)
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust.
|R
|R
|
|
|-
|-
|SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|The type of service or team within a Mental Health Service that a patient was referred to
|The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer.
|M
|
|-
|REFERRAL CLOSURE DATE
|The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|R
|
|A01 Art Therapist
|-
 
|REFERRAL CLOSURE TIME
A02 Clinical Psychologist
|The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL REJECTION DATE
|The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL REJECTION TIME
|The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL CLOSURE REASON
|The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set.
|R
|
|-
|REFERRAL REJECTION REASON
|The reason that a Referral Request has been rejected by the SERVICE.
|R
|
|}<br />


=== Referral to Treatment (RTT) ===
A03 Dietitian
{| class="wikitable"
 
!Name
A04 Dramatherapist
!Description
!Conformance
!Value Set
|-
|PATIENT PATHWAY IDENTIFIER
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY.
|R
|
|-
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER.
|R
|
|-
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH)
|The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy.
|M
|
|-
|REFERRAL TO TREATMENT PERIOD START DATE
|The start date of a REFERRAL TO TREATMENT PERIOD.
|R
|
|-
|REFERRAL TO TREATMENT PERIOD END DATE
|The end date of a REFERRAL TO TREATMENT PERIOD.
|R
|
|-
|REFERRAL TO TREATMENT PERIOD STATUS
|The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL.
|R
|
|}<br />


=== Onward Referral ===
A05 Music Therapist
{| class="wikitable"
 
!Name
A06 Occupational Therapist
!Description
 
!Conformance
A07 Orthotist
!Value Set
 
|-
A08 Physiotherapist
|DECISION TO REFER DATE (ONWARD REFERRAL)
 
|DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
A09 Podiatrist
|R
 
|
A10 Prosthetist
|-
 
|DECISION TO REFER TIME (ONWARD REFERRAL)
A11 Psychotherapist
|DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
 
|R
A12 Radiographer
|
 
|-
A13 Speech and Language Therapist
|ONWARD REFERRAL DATE
 
|The date the patient was referred to another service, which may be in the same or a different organisation.
A14 Orthoptist
|M
 
|
M01 Community Dentist
|-
 
|ONWARD REFERRAL TIME
M02 Consultant
|The time the patient was referred to another service, which may be in the same or a different organisation.
 
|R
M03 General Medical Practitioner
|
 
|-
M04 General Practitioner with an Extended Role (GPwER)
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET)
 
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation.
N01 Midwife
|R
 
|
N02 District Nurse
|-
 
|REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH)
N03 Health Visitor
|The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy.
 
|R
N04 Macmillan Nurse
|
 
|-
N05 School Nurse
|ORGANISATION IDENTIFIER (RECEIVING)
 
|ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider.
N06 Specialist Nursing - Active Case Management (Community Matrons)
|R
 
|
N07 Specialist Nursing - Arthritis Nursing/Liaison
|-
 
|CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
N08 Specialist Nursing - Asthma and Respiratory Nursing/Liaison
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed.
 
|R
N09 Specialist Nursing - Breast Care Nursing/Liaison
|
|}<br />


=== Discharge Plan Agreement ===
N10 Specialist Nursing - Cancer Related
{| class="wikitable"
 
!Name
N11 Specialist Nursing - Cardiac Nursing/Liaison
!Description
 
!Conformance
N12 Specialist Nursing - Children's Services
!Value Set
 
|-
N13 Specialist Nursing - Community Cystic Fibrosis
|DISCHARGE PLAN CONTENT AGREED BY
 
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT.
N14 Specialist Nursing - Continence Services
|M
 
|
N15 Specialist Nursing - Diabetic Nursing/Liaison
|-
 
|DISCHARGE PLAN CONTENT AGREED DATE
N16 Specialist Nursing - Enteral Feeding Nursing Services
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
 
|R
N17 Specialist Nursing - Haemophilia Nursing Services
|
 
|-
N19 Specialist Nursing - Infectious Diseases
|DISCHARGE PLAN CONTENT AGREED TIME
 
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
N20 Specialist Nursing - Intensive Care Nursing
|R
 
|
N21 Specialist Nursing - Palliative/Respite Care
|}<br />
 
N22 Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison
 
N23 Specialist Nursing - Rehabilitation Nursing


=== Medication Prescription ===
N24 Specialist Nursing - Stoma Care Services
{| class="wikitable"
 
!Name
N25 Specialist Nursing - Tissue Viability Nursing/Liaison
!Description
 
!Conformance
N26 Specialist Nursing - Transplantation Patients Nursing Services
!Value Set
 
|-
N27 Specialist Nursing - Treatment Room Nursing Services
|PRESCRIPTION IDENTIFIER
 
|The unique identifier of a PRESCRIPTION.
N28 Specialist Nursing - Tuberculosis Specialist Nursing
|P
 
|
N29 Specialist Nursing - Other Specialist Nursing
 
N30 Specialist Nursing - Safeguarding
 
N31 Practice Nursing
 
N32 Staff Nurse
 
N33 Other Registered Nurse
 
N34 Public Health Nurse
 
C01 Appliances Technician
 
C02 Audiologist
 
C03 Counsellor
 
C04 Nursery Nurse
 
C06 Play Therapist
 
C07 Social Worker
 
C08 Voluntary Care Worker
 
C09 Screener (in a National Screening Programme)
 
C99 Other Care Professional (not listed)
|-
|-
|PRESCRIPTION DATE (MEDICATION)
|CLINICAL RESPONSE PRIORITY TYPE
|The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|The clinical response priority of a SERVICE REQUEST.
|P
|R
|
|1 - Emergency
 
2 - Urgent/Serious
 
3 - Routine
 
4 - Very Urgent
|-
|-
|PRESCRIPTION TIME (MEDICATION)
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service
|P
|R
|
|01 - (Suspected) First Episode Psychosis
|}<br />
 
02 - Ongoing or Recurrent Psychosis
 
03 - Bi polar disorder
 
04 - Depression
 
05 - Anxiety
 
06 - Obsessive compulsive disorder
 
07 - Phobias
 
08 - Organic brain disorder
 
09 - Drug and alcohol difficulties
 
10 - Unexplained physical symptoms
 
11 - Post-traumatic stress disorder
 
12 - Eating disorders
 
13 - Perinatal mental health issues
 
14 - Personality disorders
 
15 - Self harm behaviours
 
16 - Conduct disorders
 
18 - In crisis
 
19 - Relationship difficulties
 
20 - Gender Discomfort issues
 
21 - Attachment difficulties
 
22 - Self - care issues
 
23 - Adjustment to health issues
 
24 - Neurodevelopmental Conditions, excluding Autism
 
25 - Suspected Autism
 
26 - Diagnosed Autism
 
27 - Preconception perinatal mental health concern
 
28 - Gambling disorder
 
29 - Community Perinatal Mental Health Partner Assessment


=== Care Contact ===
30 - Behaviours that challenge due to a Learning Disability
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|CARE CONTACT IDENTIFIER
|REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH)
|The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned.
|The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES.
|M
|R
|
|10 - Unavailability of bed at referring organisation
 
11 - Safeguarding
 
12 - Offending restrictions
 
13 - Staff member or family/friend within the referring organisation
 
14 - Patient choice
 
15 - Patient away from home
 
99 - Not Known (Not Recorded)
|-
|-
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT)
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|R
|R
|
|
|-
|-
|CARE CONTACT DATE
|DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT)
|The date on which a Care Contact took place, or, if cancelled, was scheduled to take place.
|The time that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|M
|R
|
|
|-
|-
|CARE CONTACT TIME
|DISCHARGE PLAN CREATION DATE
|The time at which a Care Contact took place.
|The date that a Discharge Plan was created for a patient.
|R
|R
|
|
|-
|-
|ADMINISTRATIVE CATEGORY CODE
|DISCHARGE PLAN CREATION TIME
|This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed.  
|The time that a Discharge Plan was created for a patient.
|R
|R
|
|
|-
|-
|CLINICAL CONTACT DURATION OF CARE CONTACT
|DISCHARGE PLAN LAST UPDATED DATE
|The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes.
|The date that the Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Date.
|R
|R
|
|
|-
|-
|CONSULTATION TYPE
|DISCHARGE PLAN LAST UPDATED TIME
|The type of consultation between the CARE PROFESSIONAL and the PATIENT.
|The time that a Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Time.
|R
|R
|
|
|-
|-
|CARE CONTACT SUBJECT
|SERVICE DISCHARGE DATE
|The person who was the subject of the Care Contact.
|Service Discharge Date is the date a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
|R
|R
|
|
|-
|-
|CONSULTATION MECHANISM (MENTAL HEALTH)
|SERVICE DISCHARGE TIME
|The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS.
|Service Discharge Time is the time a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
|R
|R
|
|
|}<br />
=== Other Reason for Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|ACTIVITY LOCATION TYPE CODE
|OTHER REASON FOR REFERRAL (MENTAL HEALTH)
|The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent.
|The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service.
|R
|M
|
|1 - (Suspected) First Episode Psychosis
|-
 
|PLACE OF SAFETY INDICATOR
2 - Ongoing or Recurrent Psychosis
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY.
 
|R
3 - Bi polar disorder
|
 
4 - Depression
 
5 - Anxiety
 
6 - Obsessive compulsive disorder
 
7 - Phobias
 
8 - Organic brain disorder
 
9 - Drug and alcohol difficulties
 
10 - Unexplained physical symptoms
 
11 - Post-traumatic stress disorder
 
12 - Eating disorders
 
13 - Perinatal mental health issues
 
14 - Personality disorders
 
15 - Self harm behaviours
 
16 - Conduct disorders
 
18 - In crisis
 
19 - Relationship difficulties
 
20 - Gender Discomfort issues
 
21 - Attachment difficulties
 
22 - Self - care issues
 
23 - Adjustment to health issues
 
24 - Neurodevelopmental Conditions, excluding Autism
 
25 - Suspected Autism
 
26 - Diagnosed Autism
 
27 - Preconception perinatal mental health concern
 
28 - Gambling disorder
 
29 - Community Perinatal Mental Health Partner Assessment
 
30 - Behaviours that challenge due to a Learning Disability
|}<br />
 
=== Service or Team Type Referred To ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|ORGANISATION SITE IDENTIFIER (OF TREATMENT)
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated.
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|R
|R
|
|
|-
|-
|COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR
|SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
|An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service.
|The type of service or team within a Mental Health Service that a patient was referred to
|R
|M
|
|A01 Day Care Service
|-
A02 Crisis Resolution Team/Home Treatment Service
|PLANNED CARE CONTACT INDICATOR
 
|An indication as to whether a Care Contact is a result of a Planned Appointment.
A05 Primary Care Mental Health Service
|R
 
|
A06 Community Mental Health Team - Functional
|-
 
|CARE CONTACT PATIENT THERAPY MODE
A07 Community Mental Health Team - Organic
|The mode of therapy for the patient during a Care Contact.
 
|R
A08 Assertive Outreach Team
|
 
|-
A09 Community Rehabilitation Service
|ATTENDED OR DID NOT ATTEND CODE
 
|This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given.
A10 General Psychiatry Service
|R
 
|
A11 Psychiatric Liaison Service
|-
 
|EARLIEST REASONABLE OFFER DATE
A12 Psychotherapy Service
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission.
 
|R
A13 Psychological Therapy Service (non IAPT)
|
 
|-
A14 Early Intervention Team for Psychosis
|EARLIEST CLINICALLY APPROPRIATE DATE
 
|The earliest DATE that it was clinically appropriate for an ACTIVITY to take place.
A15 Young Onset Dementia Team
|R
 
|
A16 Personality Disorder Service
|-
 
|CARE CONTACT CANCELLATION DATE
A17 Memory Services/Clinic/Drop in service
|The date that a Care Contact was cancelled by the Provider or Patient.
 
|R
A18 Single Point of Access Service
|
 
|-
A19 24/7 Crisis Response Line
|CARE CONTACT CANCELLATION REASON
 
|The reason that a Care Contact was cancelled.
A20 Health Based Place Of Safety Service
|R
 
|
A21 Crisis Café/Safe Haven/Sanctuary Service
|-
 
|REASONABLE ADJUSTMENT MADE INDICATOR
A22 Walk-in Crisis Assessment Unit Service
|Was a reasonable adjustment made for this patient?
 
|R
A23 Psychiatric Decision Unit Service
|
 
|}<br />
A24 Acute Day Service
 
A25 Crisis House Service
 
B01 Forensic Mental Health Service
 
B02 Forensic Learning Disability Service
 
C01 Autism Service


=== Care Activity ===
C02 Specialist Perinatal Mental Health Community Service
{| class="wikitable"
 
!Name
C04 Neurodevelopment Team
!Description
 
!Conformance
C05 Paediatric Liaison Service
!Value Set
 
C06 Looked After Children Service
 
C07 Youth Offending Service
 
C08 Acquired Brain Injury Service
 
C10 Community Eating Disorder Service
 
D01 Substance Misuse Team
 
D02 Criminal Justice Liaison and Diversion Service
 
D03 Prison Psychiatric Inreach Service
 
D04 Asylum Service
 
D05 Individual Placement and Support Service
 
D06 Mental Health In Education Service
 
D07 Problem Gambling Service
 
D08 Rough Sleeping Service
 
E01 Community Team for Learning Disabilities
 
E02 Epilepsy/Neurological Service
 
E03 Specialist Parenting Service
 
E04 Enhanced/Intensive Support Service
 
F01 Mental Health Support Team
 
F02 Maternal Mental Health Service
 
F03 Mental Health Services for Deaf people
 
F04 Veterans Complex Treatment Service
 
F05 Enhanced care in care homes teams
 
F06 Mental Health and Wellbeing Hubs
 
Z01 Other Mental Health Service - in scope of National Tariff Payment System
 
Z02 Other Mental Health Service - out of scope of National Tariff Payment System
|-
|-
|CARE ACTIVITY IDENTIFIER
|REFERRAL CLOSURE DATE
|The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned.
|The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|M
|R
|
|
|-
|-
|CLINICAL CONTACT DURATION OF CARE ACTIVITY
|REFERRAL CLOSURE TIME
|The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY.
|The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|R
|
|
|-
|-
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|REFERRAL REJECTION DATE
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.
|The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|R
|
|
|-
|-
|FINDING SCHEME IN USE (MENTAL HEALTH)
|REFERRAL REJECTION TIME
|The code scheme basis of a finding.
|The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|R
|
|
|-
|-
|CODED FINDING (CODED CLINICAL ENTRY)
|REFERRAL CLOSURE REASON
|A unique identifier for a finding from a specific classification or clinical terminology.
|The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set.
|R
|R
|
|01 - Admitted elsewhere (at the same or other Health Care Provider)
 
02 - Treatment completed
 
03 - Moved out of the area
 
04 - No further treatment appropriate
 
05 - Patient did not attend
 
06 - Patient died
 
07 - Patient requested discharge
 
08 - Referred to other specialty/Service (at the same or other Health Care Provider)
 
09 - PATIENT refused to be seen
|-
|-
|CODED OBSERVATION (SNOMED CT)
|REFERRAL REJECTION REASON
|A unique identifier for an observation from a specific clinical terminology.
|The reason that a Referral Request has been rejected by the SERVICE.
|R
|R
|
|01 - Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider)
|-
 
|OBSERVATION VALUE
02 - Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider)
|The numeric value resulting from a clinical observation.
 
03 - Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST)
|}<br />
 
=== Referral to Treatment (RTT) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PATIENT PATHWAY IDENTIFIER
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY.
|R
|R
|
|
|-
|-
|UCUM UNIT OF MEASUREMENT
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>.
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER.
|R
|R
|
|
|}<br />
=== Other in Attendance ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH)
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT.
|The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy.
|M
|M
|
|02 - Allied Health Professional Referral To Treatment Measurement
 
09 - Other Referral To Treatment Measurement Type (not listed)
|-
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE
|REFERRAL TO TREATMENT PERIOD START DATE
|Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care
|The start date of a REFERRAL TO TREATMENT PERIOD.
|R
|R
|
|
|-
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE
|REFERRAL TO TREATMENT PERIOD END DATE
|Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care
|The end date of a REFERRAL TO TREATMENT PERIOD.
|R
|R
|
|
|}<br />
|-
 
|REFERRAL TO TREATMENT PERIOD STATUS
=== Indirect Activity ===
|The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL.
|R
|10 - First activity in a Referral to Treatment Period
 
11 - First activity at the start of a new Referral to Treatment Period following Active Monitoring
 
12 - First activity at the start of a new Referral to Treatment Period following a decision to refer directly to the consultant or NHS Allied Health Professional Service (Referral To Treatment Measurement) for a separate condition
 
20 - Subsequent activity during a Referral to Treatment Period - further activities anticipated
 
21 - Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated
 
30 - End of the Referral to Treatment Period: Start of First Definitive Treatment
 
31 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient
 
32 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional
 
33 - End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral
 
34 - End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required
 
35 - End of the Referral to Treatment Period: patient declined offered treatment
 
36 - End of the Referral to Treatment Period: patient died before treatment
 
90 - Not part of a Referral to Treatment Period: After treatment - First Definitive Treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment)
 
91 - Not part of a Referral to Treatment Period: Care activity during Active Monitoring
 
92 - Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral
 
98 - Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods
 
99 - Referral to Treatment Period status not yet known
|}<br />
 
=== Onward Referral ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|INDIRECT ACTIVITY DATE
|DECISION TO REFER DATE (ONWARD REFERRAL)
|The date that the indirect activity took place
|DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
|M
|
|-
|INDIRECT ACTIVITY TIME
|The time that the indirect activity took place
|R
|R
|
|
|-
|-
|DURATION OF INDIRECT ACTIVITY
|DECISION TO REFER TIME (ONWARD REFERRAL)
|The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided.
|DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
|R
|R
|
|
|-
|-
|CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|ONWARD REFERRAL DATE
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed.
|The date the patient was referred to another service, which may be in the same or a different organisation.
|R
|
|}<br />
 
=== Group Session ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|GROUP SESSION IDENTIFIER
|The GROUP SESSION IDENTIFIER  is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned.
|M
|M
|
|
|-
|-
|GROUP SESSION DATE
|ONWARD REFERRAL TIME
|The date that a Group Session took place, or, if cancelled, was scheduled to take place.
|The time the patient was referred to another service, which may be in the same or a different organisation.
|M
|
|-
|CLINICAL CONTACT DURATION OF GROUP SESSION
|The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided.
|R
|R
|
|
|-
|-
|GROUP SESSION TYPE (MENTAL HEALTH)
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET)
|The type of Group Session provided by a Mental Health Service.
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation.
|R
|R
|
|01 - Transfer of Clinical Responsibility
02 - For Opinion Only
 
03 - For Diagnostic Test Only
 
04 - New Referral (Non Transfer)
 
96 - Other (not listed)
 
98 - Onward Referral Reason Not Applicable
 
99 - Not Known (Not Recorded)
|-
|-
|NUMBER OF GROUP SESSION PARTICIPANTS
|REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH)
|The number of persons who participated in the Group Session excluding the care professionals.
|The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy.
|R
|10 - Unavailability of bed at referring organisation
 
11 - Safeguarding
 
12 - Offending restrictions
 
13 - Staff member or family/friend within the referring organisation
 
14 - Patient choice
 
99 - Not Known (Not Recorded)
|-
|ORGANISATION IDENTIFIER (RECEIVING)
|ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider.
|R
|
|-
|CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed.
|R
|R
|
|
|}<br />
|}<br />


=== Mental Health Drop In Contact ===
=== Discharge Plan Agreement ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|MENTAL HEALTH DROP IN CONTACT IDENTIFIER
|DISCHARGE PLAN CONTENT AGREED BY
|The Mental Health DROP IN CONTACT IDENTIFIER  is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned.
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT.
|M
|M
|
|10 - Patient or Patient Proxy
 
12 - Advocate
 
13 - Clinical Service or Team
 
14 - Local Community Support Team
 
15 - Current Commissioner
 
16 - Commissioner of Planned Discharge Destination
 
17 - Family member or carer with parental responsibility
 
18 - Family member or carer without parental responsibility
|-
|-
|CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT)
|DISCHARGE PLAN CONTENT AGREED DATE
|The date that a Drop In Contact took place.
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|M
|R
|
|
|-
|-
|MENTAL HEALTH DROP IN CONTACT SERVICE TYPE
|DISCHARGE PLAN CONTENT AGREED TIME
|The type of SERVICE where the Mental Health Drop In Contact took place.
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|R
|R
|
|}<br />
=== Medication Prescription ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PRESCRIPTION IDENTIFIER
|The unique identifier of a PRESCRIPTION.
|P
|
|
|-
|-
|START TIME (MENTAL HEALTH DROP IN CONTACT)
|PRESCRIPTION DATE (MEDICATION)
|The Start Time of the Mental Health Drop In Contact as reported by the Care Professional.
|The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|R
|P
|
|
|-
|-
|END TIME (MENTAL HEALTH DROP IN CONTACT)
|PRESCRIPTION TIME (MEDICATION)
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional.
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|R
|P
|
|
|}<br />
|}<br />


=== Mental Health Act Legal Status Classification Assignment Period ===
=== Care Contact ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
|CARE CONTACT IDENTIFIER
|A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period.
|The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned.
|M
|M
|
|
|-
|-
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period.
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|M
|R
|
|
|-
|-
|START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|CARE CONTACT DATE
|The Start Time of the Mental Health Act Legal Status Classification Assignment Period.  
|The date on which a Care Contact took place, or, if cancelled, was scheduled to take place.
|M
|M
|
|
|-
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON
|CARE CONTACT TIME
|The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period.
|The time at which a Care Contact took place.
|R
|R
|
|
|-
|-
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|ADMINISTRATIVE CATEGORY CODE
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed.  
|R
|R
|
|01 - NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)
 
02 - Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006
 
03 - Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006
 
04 - Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff.
 
98 - Not applicable
 
99 - ADMINISTRATIVE CATEGORY CODE not known
|-
|-
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|CLINICAL CONTACT DURATION OF CARE CONTACT
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes.
|R
|R
|
|
|-
|-
|END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|CONSULTATION TYPE
|The date on which the Mental Health Act Legal Status Classification Assignment Period ended.
|The type of consultation between the CARE PROFESSIONAL and the PATIENT.
|R
|R
|
|01 - Initial Consultation
 
02 - Follow-up Consultation
|-
|-
|END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|CARE CONTACT SUBJECT
|The time on which the Mental Health Act Legal Status Classification Period ended.
|The person who was the subject of the Care Contact.
|R
|R
|
|01 - Patient
 
02 - Patient Proxy
|-
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON
|CONSULTATION MECHANISM (MENTAL HEALTH)
|The reason for the end of the Mental Health Act Legal Status Classification Assignment Period.
|The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS.
|R
|R
|
|01 - Face to face
 
02 - Telephone
 
04 - Talk type for a person unable to speak
 
05 - Email
 
09 - Text Message (Asynchronous)
 
10 - Instant messaging (Synchronous)
 
11 - Video consultation
 
12 - Message Board (Asynchronous)
 
13 - Chat Room (Synchronous)
 
98 - Other (not listed)
|-
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
|ACTIVITY LOCATION TYPE CODE
|'A code to identify the classification of Mental Health Act Legal Status.
|The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent.
|R
|R
|
|A01 Patient's home
|-
 
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY
A02 Carer's home
|The primary reason for the detention of PATIENTS.
 
|R
A03 Patient's workplace
|
 
|}<br />
A04 Other patient related location
 
B01 Primary Care Health Centre
 
B02 Polyclinic


=== Mental Health Responsible Clinician Assignment Period ===
C01 General Medical Practitioner Practice
{| class="wikitable"
 
!Name
C02 Dental Practice
!Description
 
!Conformance
C03 Ophthalmic Medical Practitioner premises
!Value Set
 
|-
D01 Walk In Centre
|START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
 
|The start date of an assignment of a Mental Health Responsible Clinician to a patient.
D02 Out of Hours Centre
|M
 
|
D03 Emergency Community Dental Service
|-
 
|END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
E01 Out-Patient Clinic
|The end date of an assignment of a Mental Health Responsible Clinician to a patient.
 
|R
E02 Ward
|
 
|}<br />
E03 Day Hospital
 
E04 Emergency Care Department or Minor Injuries Department
 
E99 Other departments
 
F01 Hospice
 
G01 Care Home Without Nursing


=== Conditional Discharge ===
G02 Care Home With Nursing
{| class="wikitable"
 
!Name
G03 Children’s Home
!Description
 
!Conformance
G04 Integrated Care Home Without Nursing and Care Home With Nursing
!Value Set
 
|-
H01 Day Centre
|START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
 
|The start date of the Mental Health Conditional Discharge Period.
J01 Resource Centre
|M
 
|
K01 Sure Start Children’s Centre
|-
 
|END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
K02 Child Development Centre
|The end date of the Mental Health Conditional Discharge Period.
 
L01 School
 
L02 Further Education College
 
L03 University
 
L04 Nursery Premises
 
L05 Other Childcare Premises
 
L06 Training Establishments
 
L99 Other Educational Premises
 
M01 Prison
 
M02 Probation Service Premises
 
M03 Police Station / Police Custody Suite
 
M04 Young Offender Institution
 
M06 Young Offender Institution (15-17)
 
M07 Young Offender Institution (18-21)
 
M05 Immigration Removal Centre
 
N01 Street or other public open space
 
N02 Other publicly accessible area or building
 
N03 Voluntary or charitable agency premises
 
N04 Dispensing Optician premises
 
N05 Dispensing Pharmacy premises
 
X01 Other locations not elsewhere classified
 
1 General Health Promotion Session
 
2 Telephone Support Sessiom
 
3 Thereputic Group Session
|-
|PLACE OF SAFETY INDICATOR
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY.
|R
|R
|
|Y - Yes – is being used as a Place of Safety
 
N - No – is not being used as a Place of Safety
|-
|-
|MENTAL HEALTH CONDITIONAL DISCHARGE END REASON
|ORGANISATION SITE IDENTIFIER (OF TREATMENT)
|The reason a Mental Health Conditional Discharge Period ended.  
|The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated.
|R
|R
|
|
|-
|-
|MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY
|COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR
|The body or PERSON responsible for granting Mental Health Absolute Discharge.
|An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service.
|R
|R
|
|Y - Yes - a Community Perinatal Mental Health Partner Assessment has been offered
|}<br />


=== Community Treatment Order Recall ===
N - No - a Community Perinatal Mental Health Partner Assessment has not been offered
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|START DATE (COMMUNITY TREATMENT ORDER RECALL)
|PLANNED CARE CONTACT INDICATOR
|The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|An indication as to whether a Care Contact is a result of a Planned Appointment.
|M
|
|-
|EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL)
|The date which the Community Treatment Order for a patient was due to expire.  This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended
|R
|R
|
|Y - Yes - the care contact is a result of a planned Appointment
 
N - No - the care contact is not a result of a planned appointment
|-
|-
|END DATE (COMMUNITY TREATMENT ORDER RECALL)
|CARE CONTACT PATIENT THERAPY MODE
|The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|The mode of therapy for the patient during a Care Contact.
|R
|R
|
|1 - Individual patient
 
2 - Couple
 
3 - Group Therapy
|-
|-
|COMMUNITY TREATMENT ORDER END REASON
|ATTENDED OR DID NOT ATTEND CODE
|The reason for the termination of a period of a Community Treatment Order.
|This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given.
|R
|5 - Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT
6 - Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen
 
7 - Patient arrived late and could not be seen
 
2 - APPOINTMENT cancelled by, or on behalf of, the PATIENT
 
3 - Did not attend - no advance warning given
 
4 - Appointment cancelled or postponed by the health care provider
|-
|EARLIEST REASONABLE OFFER DATE
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission.
|R
|
|-
|EARLIEST CLINICALLY APPROPRIATE DATE
|The earliest DATE that it was clinically appropriate for an ACTIVITY to take place.
|R
|
|-
|CARE CONTACT CANCELLATION DATE
|The date that a Care Contact was cancelled by the Provider or Patient.
|R
|R
|
|
|-
|CARE CONTACT CANCELLATION REASON
|The reason that a Care Contact was cancelled.
|R
|01 - Cancelled for Clinical Reasons
02 - Cancelled for Non-clinical Reasons
|-
|REASONABLE ADJUSTMENT MADE INDICATOR
|Was a reasonable adjustment made for this patient?
|R
|Y - Yes - a Reasonable Adjustment was made for the patient
N - No - a Reasonable Adjustment was not made for the patient
X - Not applicable
|}<br />
|}<br />


=== Community Treatment Order Recall ===
=== Care Activity ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|START TIME (COMMUNITY TREATMENT ORDER RECALL)
|CARE ACTIVITY IDENTIFIER
|The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned.
|M
|M
|
|
|-
|-
|END TIME (COMMUNITY TREATMENT ORDER RECALL)
|CLINICAL CONTACT DURATION OF CARE ACTIVITY
|The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY.
|R
|R
|
|
|}<br />
=== Hospital Provider Spell ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|HOSPITAL PROVIDER SPELL IDENTIFIER
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|A unique identifier for each Hospital Provider Spell for a Health Care Provider.
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.
|M
|R
|
|
|-
|-
|DECIDED TO ADMIT DATE
|FINDING SCHEME IN USE (MENTAL HEALTH)
|The date a DECISION TO ADMIT was made.
|The code scheme basis of a finding.
|R
|R
|
|01 - ICD-10
 
04 - SNOMED CT®
|-
|-
|DECIDED TO ADMIT TIME
|CODED FINDING (CODED CLINICAL ENTRY)
|The time a DECISION TO ADMIT was made.
|A unique identifier for a finding from a specific classification or clinical terminology.
|R
|R
|
|
|-
|-
|START DATE (HOSPITAL PROVIDER SPELL)
|CODED OBSERVATION (SNOMED CT)
|The start date of a Hospital Provider Spell.
|A unique identifier for an observation from a specific clinical terminology.
|M
|R
|
|
|-
|-
|START TIME (HOSPITAL PROVIDER SPELL)
|OBSERVATION VALUE
|The start time of a Hospital Provider Spell.
|The numeric value resulting from a clinical observation.
|R
|R
|
|
|-
|-
|ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|UCUM UNIT OF MEASUREMENT
|The source of admission to a Hospital Provider Spell.
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>.
|R
|R
|
|
|}<br />
=== Other in Attendance ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT
|The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission.  
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT.
|R
|M
|
|01 - Independent Advocate (Family Member)
 
02 - Independent Advocate (Independent Person)
 
03 - Independent Mental Capacity Advocate (IMCA)
 
04 - Independent Mental Health Advocate (IMHA)
 
05 - Non-Instructed Advocate
 
10 - Parent or relative (Non-Advocate)
 
11 - Friend or neighbour (Non-Advocate)
 
12 - Care Worker (Non-Advocate)
|-
|-
|POSTCODE OF MAIN VISITOR
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE
|The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell.
|Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|R
|
|01 - PATIENT has chosen not to have an Independent Mental Health Advocate
 
02 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken
 
03 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought
 
04 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken
 
05 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought
 
98 - Other (not listed)
 
99 - Not applicable (no requirement for an Independent Mental Capacity Advocate)
|-
|-
|ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE
|The estimated discharge date from a Hospital Provider Spell.
|Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|R
|
|01 - Patient has chosen not to have an Independent Mental Health Advocate
 
02 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken
 
03 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought
 
04 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken
 
05 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought
 
98 - Other (not listed)
 
99 - Not applicable (no requirement for an Independent Mental Health Advocate)
|}<br />
 
=== Indirect Activity ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|INDIRECT ACTIVITY DATE
|The planned discharge date from a Hospital Provider Spell.
|The date that the indirect activity took place
|R
|M
|
|
|-
|-
|PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|INDIRECT ACTIVITY TIME
|The planned destination of a PATIENT on completion of a Hospital Provider Spell.
|The time that the indirect activity took place
|R
|R
|
|
|-
|-
|DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|DURATION OF INDIRECT ACTIVITY
|The discharge date from a Hospital Provider Spell.
|The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided.
|R
|R
|
|
|-
|-
|DISCHARGE TIME (HOSPITAL PROVIDER SPELL)
|CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|The discharge time from a Hospital Provider Spell.
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed.
|R
|R
|
|
|}<br />
=== Group Session ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|GROUP SESSION IDENTIFIER
|The method of discharge from a Hospital Provider Spell.
|The GROUP SESSION IDENTIFIER  is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned.
|R
|M
|
|
|-
|-
|DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|GROUP SESSION DATE
|The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died.
|The date that a Group Session took place, or, if cancelled, was scheduled to take place.
|R
|M
|
|
|-
|-
|POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)
|CLINICAL CONTACT DURATION OF GROUP SESSION
|The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell.
|The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided.
|R
|R
|
|
|-
|-
|TRANSFORMING CARE INDICATOR
|GROUP SESSION TYPE (MENTAL HEALTH)
|Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|The type of Group Session provided by a Mental Health Service.
|R
|R
|
|01 - General Health Promotion Session
 
02 - Telephone Support Session
 
03 - Therapeutic Group Session
|-
|-
|TRANSFORMING CARE CATEGORY
|NUMBER OF GROUP SESSION PARTICIPANTS
|Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|The number of persons who participated in the Group Session excluding the care professionals.
|R
|R
|
|
|}<br />
|}<br />


=== Ward Stay ===
=== Mental Health Drop In Contact ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|WARD STAY IDENTIFIER
|MENTAL HEALTH DROP IN CONTACT IDENTIFIER
|A unique identifier allocated for each Ward Stay during the hospital provider spell.  
|The Mental Health DROP IN CONTACT IDENTIFIER  is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned.
|M
|M
|
|
|-
|-
|START DATE (WARD STAY)
|CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT)
|The start date of a ward stay.
|The date that a Drop In Contact took place.
|M
|M
|
|
|-
|-
|START TIME (WARD STAY)
|MENTAL HEALTH DROP IN CONTACT SERVICE TYPE
|The start time of a ward stay.
|The type of SERVICE where the Mental Health Drop In Contact took place.
|R
|R
|
|A17 - Memory Services/Clinic/Drop In Service
 
A19 - 24/7 Crisis Response Line
 
A21 - Crisis Café/Safe Haven/Sanctuary Service
|-
|-
|END DATE (MENTAL HEALTH TRIAL LEAVE)
|START TIME (MENTAL HEALTH DROP IN CONTACT)
|The End Date of a period of Mental Health Trial Leave for a PATIENT.
|The Start Time of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|R
|
|
|-
|-
|END DATE (WARD STAY)
|END TIME (MENTAL HEALTH DROP IN CONTACT)
|The end date of a ward stay.
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|R
|
|
|-
|-
|END TIME (WARD STAY)
|MENTAL HEALTH DROP IN CONTACT OUTCOME
|The end time of a ward stay.
|The outcome of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|
|-
|WARD SETTING TYPE (MENTAL HEALTH)
|The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell.
|R
|R
|01 - Caller Disconnected
02 - Advice on call only
03 - Signposted to other non-NHS services sources of support
04 - Non-urgent referral to other NHS service
05 - Urgent referral for face to face assessment
06 - Emergency Service(s) notified
98 - Other (not listed)
|}<br />
=== Mental Health Act Legal Status Classification Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
|A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period.
|M
|
|
|-
|-
|INTENDED AGE GROUP (MENTAL HEALTH)
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The age group of PATIENTS intended to use a WARD indicated in the operational plan.
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period.
|R
|M
|
|
|-
|-
|SEX OF PATIENTS CODE (MENTAL HEALTH)
|START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed.
|The Start Time of the Mental Health Act Legal Status Classification Assignment Period.  
|R
|M
|
|
|-
|-
|INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH)
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON
|The intended level of resources and intensity of care for the ward in which the person is placed.
|The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period.
|R
|R
|
|01 - Change in Mental Health Act Legal Status Classification Code (including from informal)
 
04 - Transfer from other Health Care Provider
|-
|-
|WARD SECURITY LEVEL
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|The level of security for a ward.
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|R
|
|
|-
|-
|LOCKED WARD INDICATOR
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit.
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|R
|
|
|-
|-
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
|END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The classification of the admitted PATIENT during a Ward Stay.
|The date on which the Mental Health Act Legal Status Classification Assignment Period ended.
|R
|R
|
|
|-
|-
|WARD CODE
|END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|A unique identification of a WARD within a Health Care Provider.
|The time on which the Mental Health Act Legal Status Classification Period ended.
|R
|R
|
|
|}<br />
=== Assigned Care Professional ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON
|The start date of an assignment of a Care Professional responsible for the care of the patient.
|The reason for the end of the Mental Health Act Legal Status Classification Assignment Period.
|M
|
|-
|END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|The end date of an assignment of a Care Professional responsible for the care of the patient.
|R
|R
|
|01 - Change in Mental Health Act Legal Status Classification Code (including to informal)
 
04 - Transfer to other Health Care Provider
 
05 - Death of patient
|-
|-
|TREATMENT FUNCTION CODE (MENTAL HEALTH)
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
|'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest.
|'A code to identify the classification of Mental Health Act Legal Status.
|R
|R
|
|01 - Informal
|}<br />
 
02 - Formally detained under Mental Health Act Section 2
 
03 - Formally detained under Mental Health Act Section 3


=== Mental Health Delayed Discharge ===
04 - Formally detained under Mental Health Act Section 4
 
05 - Formally detained under Mental Health Act Section 5 (2)
 
06 - Formally detained under Mental Health Act Section 5 (4)
 
07 - Formally detained under Mental Health Act Section 35
 
08 - Formally detained under Mental Health Act Section 36
 
09 - Formally detained under Mental Health Act Section 37 with section 41 restrictions
 
10 - Formally detained under Mental Health Act Section 37
 
12 - Formally detained under Mental Health Act Section 38
 
13 - Formally detained under Mental Health Act Section 44
 
14 - Formally detained under Mental Health Act Section 46
 
15 - Formally detained under Mental Health Act Section 47 with section 49 restrictions
 
16 - Formally detained under Mental Health Act Section 47
 
17 - Formally detained under Mental Health Act Section 48 with section 49 restrictions
 
18 - Formally detained under Mental Health Act Section 48
 
19 - Formally detained under Mental Health Act Section 135
 
20 - Formally detained under Mental Health Act Section 136
 
31 - Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991
 
32 - Formally detained under other acts
 
35 - Subject to guardianship under Mental Health Act Section 7
 
36 - Subject to guardianship under Mental Health Act Section 37
 
37 - Formally detained under Mental Health Act Section 45A (Limited direction in force)
 
38 - Formally detained under Mental Health Act Section 45A (Limitation direction ended)
 
98 - Not Applicable
 
99 - Not Known
|-
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY
|The primary reason for the detention of PATIENTS.
|R
|A - Mental disorder (Learning Disability not present or not primary reason for using Act)
 
B - Mental disorder (Learning Disability primary reason for using Act)
 
8 - Not applicable (i.e. not detained)
 
9 - Not Known (Not Recorded)
|}<br />
 
=== Mental Health Responsible Clinician Assignment Period ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
|The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place.
|The start date of an assignment of a Mental Health Responsible Clinician to a patient.
|M
|M
|
|
|-
|-
|END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
|The date that a period of delayed discharge for a patient who had previously been ready for discharge ended.  This may end because the patient was discharged or because the patient was no longer ready for discharge.
|The end date of an assignment of a Mental Health Responsible Clinician to a patient.
|R
|R
|
|}<br />
=== Conditional Discharge ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
|The start date of the Mental Health Conditional Discharge Period.
|M
|
|
|-
|-
|MENTAL HEALTH DELAYED DISCHARGE REASON
|END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
|The reason that a patient was not able to be discharged despite being medically ready for discharge.
|The end date of the Mental Health Conditional Discharge Period.
|R
|R
|
|
|-
|-
|MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE
|MENTAL HEALTH CONDITIONAL DISCHARGE END REASON
|An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable.
|The reason a Mental Health Conditional Discharge Period ended.  
|R
|R
|
|01 - Mental Health absolute discharge
 
02 - Recall of PATIENT
 
03 - Death of PATIENT
|-
|-
|ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE)
|MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY
|The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period.
|The body or PERSON responsible for granting Mental Health Absolute Discharge.
|R
|R
|
|01 - Mental Health Tribunal
 
02 - Secretary of State
|}<br />
|}<br />


=== Restrictive Intervention Incident ===
=== Community Treatment Order Recall ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER
|START DATE (COMMUNITY TREATMENT ORDER RECALL)
|A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell
|The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|M
|M
|
|
|-
|-
|START DATE (RESTRICTIVE INTERVENTION INCIDENT)
|EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL)
|The Start Date of the Restrictive Intervention Incident as reported by the Care Professional.
|The date which the Community Treatment Order for a patient was due to expire.  This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended
|M
|R
|
|
|-
|-
|START TIME (RESTRICTIVE INTERVENTION INCIDENT)
|END DATE (COMMUNITY TREATMENT ORDER RECALL)
|The Start Time of the Restrictive Intervention Incident as reported by the Care Professional.
|The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|R
|R
|
|
|-
|-
|END DATE (RESTRICTIVE INTERVENTION INCIDENT)
|COMMUNITY TREATMENT ORDER END REASON
|The End Date of the Restrictive Intervention Incident as reported by the Care Professional.
|The reason for the termination of a period of a Community Treatment Order.
|R
|R
|
|01 - Patient discharged
 
02 - Community Treatment Order revoked
 
03 - Patient died
 
04 - Patient transferred outside England
 
05 - Patient transferred to another Health Care Provider
|}<br />
 
=== Community Treatment Order Recall ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|END TIME (RESTRICTIVE INTERVENTION INCIDENT)
|START TIME (COMMUNITY TREATMENT ORDER RECALL)
|The End Time of the Restrictive Intervention Incident as reported by the Care Professional.
|The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|R
|M
|
|
|-
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT)
|END TIME (COMMUNITY TREATMENT ORDER RECALL)
|An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention.
|The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|R
|
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT)
|The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention.
|R
|
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL)
|An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention.
|R
|
|-
|RESTRICTIVE INTERVENTION REASON
|The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell.
|R
|R
|
|
|}<br />
|}<br />


=== Restrictive Intervention Type ===
=== Hospital Provider Spell ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|RESTRICTIVE INTERVENTION TYPE IDENTIFIER
|HOSPITAL PROVIDER SPELL IDENTIFIER
|A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell
|A unique identifier for each Hospital Provider Spell for a Health Care Provider.
|M
|M
|
|
|-
|-
|START DATE (RESTRICTIVE INTERVENTION TYPE)
|DECIDED TO ADMIT DATE
|The Start Date of the Restrictive Intervention Type as reported by the Care Professional.
|The date a DECISION TO ADMIT was made.
|M
|R
|
|
|-
|-
|START TIME (RESTRICTIVE INTERVENTION TYPE)
|DECIDED TO ADMIT TIME
|The Start Time of the Restrictive Intervention Type as reported by the Care Professional.
|The time a DECISION TO ADMIT was made.
|R
|R
|
|
|-
|-
|RESTRICTIVE INTERVENTION TYPE
|START DATE (HOSPITAL PROVIDER SPELL)
|Type of RESTRICTIVE INTERVENTION used.
|The start date of a Hospital Provider Spell.
|R
|M
|
|
|-
|-
|END DATE (RESTRICTIVE INTERVENTION TYPE)
|START TIME (HOSPITAL PROVIDER SPELL)
|The End Date of the Restrictive Intervention Type as reported by the Care Professional.
|The start time of a Hospital Provider Spell.
|R
|R
|
|
|-
|-
|END TIME (RESTRICTIVE INTERVENTION TYPE)
|ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|The End Time of the Restrictive Intervention Type as reported by the Care Professional.
|The source of admission to a Hospital Provider Spell.
|R
|R
|
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
 
29 - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments)
 
37 - Court
 
40 - Penal establishment
 
42 - Police Station / Police Custody Suite
 
49 - NHS other Hospital Provider - high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
 
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department
 
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
55 - Care Home With Nursing
 
56 - Care Home Without Nursing
 
66 - Local Authority foster care
 
87 - Independent Sector Healthcare Provider run hospital
 
88 - Hospice
 
98 - Not applicable
 
99 - Not Known
|-
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT)
|METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention.
|The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission.  
|R
|R
|
|11 - Elective Admission: Waiting list
 
12 - Elective Admission: Booked
 
13 - Elective Admission: Planned
 
21 - Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE
 
22 - Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy
 
23 - Emergency Admission: Bed bureau
 
24 - Emergency Admission: Consultant Clinic, of this or another Health Care Provider
 
25 - Emergency Admission: Admission via Mental Health Crisis Resolution Team
 
2A - Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted
 
2B - Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency
 
2D - Emergency Admission: Other emergency admission
 
81 - Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency
 
98 - Not applicable
 
99 - Not Known
|-
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL)
|POSTCODE OF MAIN VISITOR
|An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention.
|The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell.
|R
|R
|
|
|-
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON)
|ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention.
|The estimated discharge date from a Hospital Provider Spell.
|R
|R
|
|
|}<br />
=== Police Assistance Request ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|POLICE ASSISTANCE REQUEST DATE
|PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|The date the call was made to request police assistance
|The planned discharge date from a Hospital Provider Spell.
|M
|
|-
|POLICE ASSISTANCE REQUEST TIME
|The time the call was made to request police assistance
|R
|R
|
|
|-
|-
|POLICE ASSISTANCE ARRIVAL DATE
|PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|The date the Police arrived following the request for assistance
|The planned destination of a PATIENT on completion of a Hospital Provider Spell.
|R
|R
|
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
 
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)
 
30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
 
37 - Court
 
40 - Penal establishment
 
42 - Police Station / Police Custody Suite
 
48 - High Security Psychiatric Hospital, Scotland
 
49 - NHS other Hospital Provider - high security psychiatric accommodation
 
50 - NHS other Hospital Provider - medium secure unit
 
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled
 
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
55 - Care Home With Nursing
 
56 - Care Home Without Nursing
 
66 - Local Authority foster care
 
79 - PATIENT died or stillbirth
 
84 - Independent Sector Healthcare Provider run hospital - medium secure unit
 
87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit
 
88 - Hospice
 
89 - ORGANISATION responsible for forced repatriation
 
98 - Not applicable
 
99 - Not known
|-
|-
|POLICE ASSISTANCE ARRIVAL TIME
|DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|The time the Police arrived following the request for assistance
|The discharge date from a Hospital Provider Spell.
|R
|R
|
|
|-
|-
|POLICE RESTRAINT OR FORCE USED INDICATOR
|DISCHARGE TIME (HOSPITAL PROVIDER SPELL)
|An indication of whether the police used restraint or force on a PATIENT.
|The discharge time from a Hospital Provider Spell.
|R
|R
|
|
|}<br />
|-
|METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|The method of discharge from a Hospital Provider Spell.
|R
|1 - Patient discharged on clinical advice or with clinical consent


=== Assault ===
3 - Patient discharged by mental health review tribunal, Home Secretary or court
{| class="wikitable"
 
!Name
4 - Patient died
!Description
 
!Conformance
6 - Patient discharged him/herself
!Value Set
 
7 - Patient discharged by a relative or advocate
 
8 - Not applicable (Hospital Provider Spell not finished at episode end (i.e. not discharged) or current episode unfinished)
 
9 - Method of Discharge not known
|-
|-
|DATE OF ASSAULT ON PATIENT
|DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|The DATE that an instance of assault on the PATIENT by another PATIENT occurred.
|The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died.
|M
|R
|
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
|}<br />


=== Self-Harm ===
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|DATE OF SELF-HARM
|The date that an incident of self-harm for the patient occurred.
|M
|
|-
|OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE)
|The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL.
|M
|
|}<br />


=== Home Leave ===
30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
{| class="wikitable"
 
!Name
37 - Court
!Description
 
!Conformance
40 - Penal establishment
!Value Set
 
42 - Police Station / Police Custody Suite
 
48 - High Security Psychiatric Hospital, Scotland
 
49 - NHS other Hospital Provider - high security psychiatric accommodation
 
50 - NHS other Hospital Provider - medium secure unit
 
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled
 
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
55 - Care Home With Nursing
 
56 - Care Home Without Nursing
 
66 - Local Authority foster care
 
79 - PATIENT died or stillbirth
 
84 - Independent Sector Healthcare Provider run hospital - medium secure unit
 
87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit
 
88 - Hospice
 
89 - ORGANISATION responsible for forced repatriation
 
98 - Not applicable
 
99 - Not known
|-
|-
|START DATE (HOME LEAVE)
|POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)
|The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell.
|M
|R
|
|
|-
|-
|START TIME (HOME LEAVE)
|TRANSFORMING CARE INDICATOR
|The start time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|R
|
|Y - Yes - Patient is in scope of transforming care
 
N - No - Patient is not in scope of transforming care
|-
|-
|END DATE (HOME LEAVE)
|TRANSFORMING CARE CATEGORY
|The end date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|R
|
|1 - Patient with autism (and no learning disability)
|-
 
|END TIME (HOME LEAVE)
2 - Patient with a learning disability (and no autism)
|The end time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
 
|R
3 - Patient with autism and a learning disability
|
|}<br />
|}<br />


=== Leave Of Absence ===
=== Ward Stay ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|START DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|WARD STAY IDENTIFIER
|The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|A unique identifier allocated for each Ward Stay during the hospital provider spell.  
|M
|M
|
|
|-
|-
|START TIME (MENTAL HEALTH LEAVE OF ABSENCE)
|START DATE (WARD STAY)
|The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|The start date of a ward stay.
|R
|M
|
|
|-
|-
|END DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|START TIME (WARD STAY)
|The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|The start time of a ward stay.
|R
|R
|
|
|-
|-
|END TIME (MENTAL HEALTH LEAVE OF ABSENCE)
|END DATE (MENTAL HEALTH TRIAL LEAVE)
|The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|The End Date of a period of Mental Health Trial Leave for a PATIENT.
|R
|R
|
|
|-
|-
|MENTAL HEALTH LEAVE OF ABSENCE END REASON
|END DATE (WARD STAY)
|The reason a Mental Health Leave of Absence ended.
|The end date of a ward stay.
|R
|R
|
|
|-
|-
|ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR
|END TIME (WARD STAY)
|An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted.
|The end time of a ward stay.
|R
|R
|
|}<br />
=== Mental Health Trial Leave ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|START DATE (MENTAL HEALTH TRIAL LEAVE)
|The Start Date of a period of Mental Health Trial Leave for a PATIENT.
|M
|
|
|-
|-
|START TIME (MENTAL HEALTH TRIAL LEAVE)
|WARD SETTING TYPE (MENTAL HEALTH)
|The Start Time of a period of Mental Health Trial Leave for a PATIENT.
|The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell.
|R
|R
|
|01 - Child and Adolescent Mental Health Ward
 
02 - Paediatric Ward
 
03 - Adult Mental Health Ward
 
04 - Non Mental Health Ward
 
05 - Learning Disabilities Ward
 
06 - Older People's Mental Health Ward
|-
|-
|END TIME (MENTAL HEALTH TRIAL LEAVE)
|INTENDED AGE GROUP (MENTAL HEALTH)
|The End Time of a period of Mental Health Trial Leave for a PATIENT.
|The age group of PATIENTS intended to use a WARD indicated in the operational plan.
|R
|R
|
|10 - Child only
|}<br />
 
11 - Adolescent only
 
12 - Child and Adolescent


=== Hospital Provider Spell Commissioner Assignment Period ===
13 - Adult only
{| class="wikitable"
 
!Name
14 - Older Adult only
!Description
 
!Conformance
15 - Adult and Older Adult
!Value Set
 
99 - Any age
|-
|-
|START DATE (COMMISSIONER ASSIGNMENT PERIOD)
|SEX OF PATIENTS CODE (MENTAL HEALTH)
|The Start Date of the Commissioner Assignment Period.
|The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed.
|M
|R
|
|1 - Male
 
2 - Female
 
8 - Not specified
|-
|-
|END DATE (COMMISSIONER ASSIGNMENT PERIOD)
|INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH)
|The End Date of the Commissioner Assignment Period.
|The intended level of resources and intensity of care for the ward in which the person is placed.
|R
|R
|
|51 - Mental Illness intensive care: specially designated ward for Patients needing containment and more intensive management (e.g. Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where Patients may require one to one nursing while on a standard ward
|}<br />
 
52 - Mental Illness short stay: Patients intended to stay less than a year
 
53 - Mental Illness long stay: Patients intended to stay a year or more
 
61 - Learning Disability Patients in a designated or interim secure unit
 
62 - Learning Disability Patients intending to stay less than a year


=== Specialised Mental Health Exceptional Package of Care ===
63 - Learning Disability Patients intending to stay a year or more
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE
|WARD SECURITY LEVEL
|The amount charged for the SMH EPC in the reporting period
|The level of security for a ward.
|M
|R
|
|0 - General (non-secure)
 
1 - Low Secure
 
2 - Medium Secure
 
3 - High Secure
|-
|-
|START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|LOCKED WARD INDICATOR
|The start date of an SMH EPC.
|An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit.
|M
|
|-
|END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|The End Date of an SMH EPC.
|R
|R
|
|Y - Yes - is a locked WARD
|}<br />


=== Medical History (Previous Diagnosis) ===
N - No - is not a locked WARD
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|DIAGNOSIS SCHEME IN USE (MENTAL HEALTH)
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
|The code scheme basis of the Diagnosis.
|The classification of the admitted PATIENT during a Ward Stay.
|M
|
|-
|PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
|A unique identifier for a clinical diagnosis from a specific classification or clinical terminology.
|M
|
|-
|CODED DIAGNOSIS TIMESTAMP
|The date, time and time zone for the PATIENT DIAGNOSIS.
|R
|R
|
|10 - Acute adult mental health care
|}<br />


=== Provisional Diagnosis ===
11 - Acute older adult mental health care (organic and functional)
 
12 - Adult Psychiatric Intensive Care Unit (acute mental health care)
 
13 - Adult Eating Disorders
 
14 - Mother and baby
 
15 - Adult Learning Disabilities
 
17 - Adult High dependency rehabilitation
 
19 - Adult Low secure
 
20 - Adult Medium secure
 
21 - Adult High secure
 
22 - Adult Neuro-psychiatry / Acquired Brain Injury
 
23 - General child and young PERSON admitted PATIENT - Child (including High Dependency)
 
24 - General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency)
 
25 - Eating Disorders admitted patient - Young person (13 years and over)
 
26 - Eating Disorders admitted patient - Child (12 years and under)
 
27 - Child and Young Person Low Secure Mental Illness
 
28 - Child and Young Person Medium Secure Mental Illness
 
29 - Child Mental Health admitted patient services for the Deaf
 
30 - Child and Young Person Learning Disabilities / Autism admitted patient
 
31 - Child and Young Person Low Secure Learning Disabilities
 
32 - Child and Young Person Medium Secure Learning Disabilities
 
33 - Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person
 
34 - Child and Young Person Psychiatric Intensive Care Unit
 
35 - Adult admitted patient continuing care
 
36 - Adult community rehabilitation unit
 
37 - Adult highly specialist high dependency rehabilitation unit
 
38 - Adult longer term high dependency rehabilitation unit
 
39 - Adult mental health admitted patient services for the Deaf
 
40 - Adult personality disorder
|-
|WARD CODE
|A unique identification of a WARD within a Health Care Provider.
|R
|
|}<br />
 
=== Assigned Care Professional ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
|START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare.
|The start date of an assignment of a Care Professional responsible for the care of the patient.
|M
|M
|
|
|-
|END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|The end date of an assignment of a Care Professional responsible for the care of the patient.
|R
|
|-
|TREATMENT FUNCTION CODE (MENTAL HEALTH)
|'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest.
|R
|319 Respite Care Service
348 Post-COVID-19 Syndrome Service
656 Clinical Psychology Service
700 Learning Disability Service
710 Adult Mental Health Service
711 Child and Adolescent Psychiatry Service
712 Forensic Psychiatry Service
713 Medical Psychotherapy Service
715 Old Age Psychiatry Service
720 Eating Disorders Service
721 Addiction Service
722 Liaison Psychiatry Service
723 Psychiatric Intensive Care Service
724 Perinatal Mental Health Service
725 Mental Health Recovery and Rehabilitation Service
726 Mental Health Dual Diagnosis Service
727 Dementia Assessment Service
730 Neuropsychiatry Service
|}<br />
|}<br />


=== Primary Diagnosis ===
=== Mental Health Delayed Discharge ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY)
|START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem.
|The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place.
|M
|M
|
|
|}
<br />
=== Secondary Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY)
|END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded.
|The date that a period of delayed discharge for a patient who had previously been ready for discharge ended.  This may end because the patient was discharged or because the patient was no longer ready for discharge.
|M
|R
|
|
|-
|-
|CODED DIAGNOSIS TIMESTAMP
|MENTAL HEALTH DELAYED DISCHARGE REASON
|The date, time and time zone for the PATIENT DIAGNOSIS.
|The reason that a patient was not able to be discharged despite being medically ready for discharge.
|R
|R
|
|A2 - Awaiting care coordinator allocation
|}
 
<br />
B1 - Awaiting public funding
 
C1 - Awaiting further non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)
 
D1 - Awaiting Care Home Without Nursing placement or availability
 
D2 - Awaiting Care Home With Nursing placement or availability
 
E1 - Awaiting care package in own home
 
F2 - Awaiting community equipment, telecare and/or adaptations
 
G2 - Patient or Family choice (reason not stated by patient or family)
 
G3 - Patient or Family choice - Non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)


=== Coded Scored Assessment (Referral) ===
G4 - Patient or Family choice - Care Home Without Nursing placement
{| class="wikitable"
 
!Name
G5 - Patient or Family choice - Care Home With Nursing placement
!Description
 
!Conformance
G6 - Patient or Family choice - Care package in own home
!Value Set
 
|-
G7 - Patient or Family choice - Community equipment, telecare and/or adaptations
|CODED ASSESSMENT TOOL TYPE (SNOMED CT)
 
|The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT.
G8 - Patient or Family Choice - general needs housing/private landlord acceptance as patient NOT covered by Housing Act/Care Act
|M
 
|
G9 - Patient or Family choice - Supported accommodation
|-
 
|PERSON SCORE
G10 - Patient or Family choice - Emergency accommodation from the Local Authority under the Housing Act
|The observable value (score) resulting from an assessment.
 
|M
G11 - Patient or Family choice - Child or young person awaiting social care or family placement
|
 
|-
G12 - Patient or Family choice - Ministry of Justice agreement/permission of proposed placement
|ASSESSMENT TOOL COMPLETION TIMESTAMP
 
|The date, time and time zone on which the assessment took place
H1 - Disputes
|M
 
|
I2 - Housing - Awaiting availability of general needs housing/private landlord accommodation acceptance as patient NOT covered by Housing Act and/or Care Act
|}
 
<br />
I3 - Housing - Single homeless patients or asylum seekers NOT covered by Care Act
 
J2 - Housing - Awaiting supported accommodation
 
K2 - Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act
 
L1 - Child or young person awaiting social care or family placement
 
M1 - Awaiting Ministry of Justice agreement/permission of proposed placement
 
N1 - Awaiting outcome of legal requirements (mental capacity/mental health legislation)


=== Care Programme Approach (CPA) Care Episode ===
P1 - Awaiting residential special school or college placement or availability
{| class="wikitable"
 
!Name
Q1 - Lack of local education support
!Description
 
!Conformance
R1 - Public safety concern unrelated to clinical treatment need (care team)
!Value Set
 
R2 - Public safety concern unrelated to clinical treatment need (Ministry of Justice)
 
S1 - No lawful community care package available
 
T1 - Lack of health care service provision
 
T2 - Lack of social care support
 
98 - No reason given
|-
|-
|CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER
|MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE
|A unique identifier allocated to each Care Programme Approach Care Episode.
|An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable.
|M
|R
|
|04 - NHS, excluding housing
 
05 - Social Care, excluding housing
 
06 - Both (NHS and Social Care), excluding housing
 
07 - Housing (including supported/specialist housing)
|-
|-
|START DATE (CARE PROGRAMME APPROACH CARE)
|ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE)
|The start date for Care Programme Approach Care for the patient.
|The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period.
|M
|
|-
|END DATE (CARE PROGRAMME APPROACH CARE)
|The end date for Care Programme Approach Care for the patient.
|R
|R
|
|
|}
|}<br />
<br />


=== Care Programme Approach (CPA) Review ===
=== Restrictive Intervention Incident ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|CARE PROGRAMME APPROACH REVIEW DATE
|RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER
|The date of the Care Programme Approach review.
|A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell
|M
|M
|
|
|}
|-
<br />
|START DATE (RESTRICTIVE INTERVENTION INCIDENT)
 
|The Start Date of the Restrictive Intervention Incident as reported by the Care Professional.
=== Clustering Tool Assessment ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|CLUSTERING TOOL ASSESSMENT IDENTIFIER
|A unique identifier for each clustering tool assessment that takes place for each patient.
|M
|M
|
|
|-
|-
|CLUSTERING TOOL ASSESSMENT CATEGORY
|START TIME (RESTRICTIVE INTERVENTION INCIDENT)
|The category of the clustering tool assessment completed.
|The Start Time of the Restrictive Intervention Incident as reported by the Care Professional.
|M
|R
|
|
|-
|-
|ASSESSMENT TOOL COMPLETION DATE
|END DATE (RESTRICTIVE INTERVENTION INCIDENT)
|The date on which a clustering tool assessment was completed for a patient.
|The End Date of the Restrictive Intervention Incident as reported by the Care Professional.
|M
|
|-
|ASSESSMENT TOOL COMPLETION TIME
|The time on which a clustering tool assessment was completed for a patient.
|R
|R
|
|
|-
|-
|CLUSTERING TOOL ASSESSMENT REASON
|END TIME (RESTRICTIVE INTERVENTION INCIDENT)
|The reason that the clustering tool assessment for the patient was undertaken.
|The End Time of the Restrictive Intervention Incident as reported by the Care Professional.
|R
|R
|
|
|-
|-
|MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT)
|The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation.
|An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention.
|R
|R
|
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
 
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention
|-
|-
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL)
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT)
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm.
|The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention.
|R
|R
|
|1 - Clinical decision to delay
|-
 
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
2 - Patient refused to take part
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|}
<br />


=== Care Cluster ===
3 - Other (not listed)
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|START DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL)
|The date on which the assignment of a patient to a Care Cluster started.
|An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention.
|M
|
|-
|START TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The time on which the assignment of a patient to a Care Cluster started.
|R
|R
|
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
 
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention
|-
|-
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|RESTRICTIVE INTERVENTION REASON
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm.
|The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell.
|R
|R
|10 - Prevent a patient being violent to others
11 - Prevent a patient causing serious intentional harm to themselves
12 - Prevent a patient causing serious physical injury to themselves by accident
13 - Lawfully administer medicines or other medical treatment
14 - Facilitate personal care
15 - Facilitate nasogastric (NG) feeding
16 - Prevent the patient exhibiting extreme and prolonged over-activity
17 - Prevent the PATIENT exhibiting otherwise dangerous behaviour
18 - Undertake a search of the patient’s clothing or property to ensure the safety of others
19 - Prevent the patient absconding from lawful custody
98 - Other (not listed)
99 - Not Known (Not Recorded)
|}<br />
=== Restrictive Intervention Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|RESTRICTIVE INTERVENTION TYPE IDENTIFIER
|A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell
|M
|
|-
|START DATE (RESTRICTIVE INTERVENTION TYPE)
|The Start Date of the Restrictive Intervention Type as reported by the Care Professional.
|M
|
|
|-
|-
|CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE
|START TIME (RESTRICTIVE INTERVENTION TYPE)
|The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL.
|The Start Time of the Restrictive Intervention Type as reported by the Care Professional.
|R
|R
|
|
|-
|-
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|RESTRICTIVE INTERVENTION TYPE
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|Type of RESTRICTIVE INTERVENTION used.
|P
|R
|
|01 - Physical restraint - Prone
 
07 - Physical restraint - Standing
 
08 - Physical restraint - Restrictive escort
 
09 - Physical restraint - Supine
 
10 - Physical restraint - Side
 
11 - Physical restraint - Seated
 
12 - Physical restraint - Kneeling
 
13 - Physical restraint - Other (not listed)
 
14 - Chemical restraint - Injection (Rapid Tranquillisation)
 
15 - Chemical restraint - Injection (Non Rapid Tranquillisation)
 
16 - Chemical restraint - Oral
 
17 - Chemical restraint - Other (not listed)
 
04 - Mechanical restraint
 
05 - Seclusion
 
06 - Segregation
|-
|-
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|END DATE (RESTRICTIVE INTERVENTION TYPE)
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL.
|The End Date of the Restrictive Intervention Type as reported by the Care Professional.
|R
|R
|
|
|-
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|END TIME (RESTRICTIVE INTERVENTION TYPE)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|The End Time of the Restrictive Intervention Type as reported by the Care Professional.
|P
|R
|
|
|-
|-
|END DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT)
|The date on which the assignment of a patient to a Care Cluster ended.
|An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention.
|R
|R
|
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
 
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|-
|-
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL)
|The time on which the assignment of a patient to a Care Cluster ended.
|An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention.
|R
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
 
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON)
|An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention.
|R
|R
|
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
|}
 
<br />
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|}<br />


=== Five Forensic Pathways ===
=== Police Assistance Request ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT DATE
|POLICE ASSISTANCE REQUEST DATE
|The date on which a Five Forensic Pathways assessment was completed for a patient.
|The date the call was made to request police assistance
|M
|M
|
|
|-
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT REASON
|POLICE ASSISTANCE REQUEST TIME
|The reason for which a Five Forensic Pathways assessment was undertaken.
|The time the call was made to request police assistance
|R
|R
|
|
|-
|-
|FIVE FORENSIC PATHWAYS CODE
|POLICE ASSISTANCE ARRIVAL DATE
|The Five Forensic Pathway assigned to a patient.
|The date the Police arrived following the request for assistance
|M
|R
|
|
|}
|-
<br />
|POLICE ASSISTANCE ARRIVAL TIME
 
|The time the Police arrived following the request for assistance
=== Care Professionals ===
|R
|
|-
|POLICE RESTRAINT OR FORCE USED INDICATOR
|An indication of whether the police used restraint or force on a PATIENT.
|R
|Y - Yes - the police used restraint or force on a PATIENT
 
N - No - the police did not use restraint or force on a PATIENT
|}<br />
 
=== Assault ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|PROFESSIONAL REGISTRATION BODY CODE
|DATE OF ASSAULT ON PATIENT
|A code which identifies the PROFESSIONAL REGISTRATION BODY.
|The DATE that an instance of assault on the PATIENT by another PATIENT occurred.
|R
|M
|
|
|}<br />
=== Self-Harm ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|PROFESSIONAL REGISTRATION ENTRY IDENTIFIER
|DATE OF SELF-HARM
|The registration identifier allocated by an ORGANISATION.
|The date that an incident of self-harm for the patient occurred.
|R
|M
|
|
|-
|-
|CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE)
|The staff group of a CARE PROFESSIONAL working in a Mental Health Service.
|The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL.
|R
|M
|
|}<br />
 
=== Home Leave ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (HOME LEAVE)
|The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|M
|
|
|-
|-
|MAIN SPECIALTY CODE (MENTAL HEALTH)
|START TIME (HOME LEAVE)
|The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period.
|The start time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|R
|
|
|-
|-
|OCCUPATION CODE
|END DATE (HOME LEAVE)
|An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual.
|The end date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|R
|
|
|-
|-
|CARE PROFESSIONAL (JOB ROLE CODE)
|END TIME (HOME LEAVE)
|A National Code for a POSITION applicable to an EMPLOYEE.
|The end time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|R
|
|
|}<br />
|}<br />
== IAPT ==
<br />


=== Data Linkage ===
=== Leave Of Absence ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|START DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system.
|The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|M
|M
|
|
|}
|-
 
|START TIME (MENTAL HEALTH LEAVE OF ABSENCE)
=== Header ===
|The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
{| class="wikitable"
|R
!Name
!Description
!Conformance
!Value Set
|-
|DATA SET VERSION NUMBER
|The version of the data set that this submission file is for.
|M
|
|
|-
|-
|ORGANISATION IDENTIFIER (CODE OF PROVIDER)
|END DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database
|The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|M
|R
|
|
|-
|-
|ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
|END TIME (MENTAL HEALTH LEAVE OF ABSENCE)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation.
|The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|M
|R
|
|
|-
|-
|PRIMARY DATA COLLECTION SYSTEM IN USE
|MENTAL HEALTH LEAVE OF ABSENCE END REASON
|The name of the Primary Data Collection System in use by the Health Care Provider.
|The reason a Mental Health Leave of Absence ended.
|M
|R
|
|01 - Patient returned on or before day specified
|-
 
|REPORTING PERIOD START DATE
02 - Leave revoked and patient recalled by Mental Health Responsible Clinician
|The reporting period start date to which this file refers
 
|M
03 - Period of leave to be extended
|
 
|-
04 - Patient failed to return on or before day specified and is absent without leave
|REPORTING PERIOD END DATE
 
|The reporting period end date to which this file refers
05 - Patient's liability for detention terminated by Mental Health Responsible Clinician
|M
 
|
06 - Patient's liability for detention terminated by Mental Health Act Review Tribunal
|-
 
|DATE AND TIME DATE SET CREATED
07 - Patient's liability for detention terminated by Hospital Managers
|Date/time this upload file was created
 
|M
08 - Patient died
|
 
|}
96 - Other (not listed)


=== MPI ===
99 - MENTAL HEALTH LEAVE OF ABSENCE END REASON Not Known (Not Recorded)
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR
|The type of Educational Establishment that the student is attending.
|An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted.
|R
|R
|
|Y - Yes - a period of Mental Health Leave of Absence is escorted
|}
 
N - No - a period of Mental Health Leave of Absence is not escorted
|}<br />


=== Employment Status ===
=== Mental Health Trial Leave ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|SELF EMPLOYED INDICATOR
|START DATE (MENTAL HEALTH TRIAL LEAVE)
|'An indication of whether an employed person is self-employed.
|The Start Date of a period of Mental Health Trial Leave for a PATIENT.
|R
|M
|
|
|-
|-
|SICKNESS ABSENCE INDICATOR
|START TIME (MENTAL HEALTH TRIAL LEAVE)
|'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness.
|The Start Time of a period of Mental Health Trial Leave for a PATIENT.
|R
|R
|
|
|-
|-
|STATUTORY SICK PAY RECEIPT INDICATOR
|END TIME (MENTAL HEALTH TRIAL LEAVE)
|'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON.
|The End Time of a period of Mental Health Trial Leave for a PATIENT.
|R
|R
|
|
|}<br />
=== Hospital Provider Spell Commissioner Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|START DATE (COMMISSIONER ASSIGNMENT PERIOD)
|'An indication of whether a patient is currently receiving benefits, as stated by the patient.
|The Start Date of the Commissioner Assignment Period.
|R
|M
|
|
|-
|-
|EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR
|END DATE (COMMISSIONER ASSIGNMENT PERIOD)
|'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient.
|The End Date of the Commissioner Assignment Period.
|R
|R
|
|
|}<br />
=== Specialised Mental Health Exceptional Package of Care ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|UNIVERSAL CREDIT RECEIPT INDICATOR
|SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE
|'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient.
|The amount charged for the SMH EPC in the reporting period
|R
|M
|
|
|-
|-
|PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR
|START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient.
|The start date of an SMH EPC.
|R
|M
|
|
|-
|-
|EMPLOYMENT SUPPORT SUITABILITY INDICATOR
|END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support.
|The End Date of an SMH EPC.
|R
|R
|
|
|-
|}<br />
|EMPLOYMENT SUPPORT REFERRAL DATE
 
|The date the PATIENT was referred for Employment Support.
=== Medical History (Previous Diagnosis) ===
|R
|
|}
{| class="wikitable"
{| class="wikitable"
|+
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|DIAGNOSIS SCHEME IN USE (MENTAL HEALTH)
|The code scheme basis of the Diagnosis.
|M
|02 - ICD-10
 
06 - SNOMED CT®
|-
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE
|PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
|
|A unique identifier for a clinical diagnosis from a specific classification or clinical terminology.
|
|M
|
|
|-
|-
|CODED DIAGNOSIS TIMESTAMP
|The date, time and time zone for the PATIENT DIAGNOSIS.
|R
|
|
|}<br />
=== Provisional Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
|This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare.
|M
|
|
|
|}<br />
|
 
=== Primary Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|
|PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY)
|
|This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem.
|
|M
|
|
|}
|}
<br />


=== Referral ===
=== Secondary Diagnosis ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES
|SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY)
|The source of referral to a Mental Health Service.
|This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded.
|R
|M
|
|
|-
|-
|YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|CODED DIAGNOSIS TIMESTAMP
|The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT.
|The date, time and time zone for the PATIENT DIAGNOSIS.
|R
|R
|
|
|}
<br />
=== Coded Scored Assessment (Referral) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|PREVIOUS DIAGNOSED CONDITION INDICATOR
|CODED ASSESSMENT TOOL TYPE (SNOMED CT)
|An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT.
|The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT.
|R
|M
|
|
|-
|-
|DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON
|PERSON SCORE
|The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service.
|The observable value (score) resulting from an assessment.
|R
|M
|
|
|-
|-
|SERVICE DISCHARGE DATE
|ASSESSMENT TOOL COMPLETION TIMESTAMP
|The date a PATIENT was discharged from a SERVICE.
|The date, time and time zone on which the assessment took place
|R
|M
|
|
|}
|}
<br />


=== Onward Referral ===
=== Care Programme Approach (CPA) Care Episode ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER
|The reason why the patient was referred from one service to another service, which may be in the same or a different organisation.
|A unique identifier allocated to each Care Programme Approach Care Episode.
|R
|
|}
 
=== Waiting Time Pauses ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER
|The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION.
|M
|M
|
|
|-
|-
|ACTIVITY SUSPENSION START DATE
|START DATE (CARE PROGRAMME APPROACH CARE)
|The date on which the break from the ACTIVITY starts.
|The start date for Care Programme Approach Care for the patient.
|M
|M
|
|
|-
|-
|ACTIVITY SUSPENSION END DATE
|END DATE (CARE PROGRAMME APPROACH CARE)
|The date on which the break from the ACTIVITY ends.
|The end date for Care Programme Approach Care for the patient.
|R
|
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON
|The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set.  Patient Initiated pause in the waiting period.
|R
|R
|
|
|}
|}
<br />


=== Care Contact ===
=== Care Programme Approach (CPA) Review ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR
|CARE PROGRAMME APPROACH REVIEW DATE
|An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice.
|The date of the Care Programme Approach review.  
|R
|M
|
|
|}
<br />
=== Clustering Tool Assessment ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR
|CLUSTERING TOOL ASSESSMENT IDENTIFIER
|An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service.
|A unique identifier for each clustering tool assessment that takes place for each patient.
|M
|M
|
|
|-
|-
|APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|CLUSTERING TOOL ASSESSMENT CATEGORY
|The type of Improving Access to Psychological Therapies APPOINTMENT.
|The category of the clustering tool assessment completed.
|M
|M
|
|01 - Adult Mental Health Clustering Tool
 
03 - Learning Disabilities Clustering Tool
 
04 - Forensic Mental Health Clustering Tool
 
05 - Forensic Learning Disabilities Clustering Tool
 
06 - Child and Adolescent Mental Health Needs Based Grouping Tool
|-
|-
|INTERNET ENABLED THERAPY PROGRAMME
|ASSESSMENT TOOL COMPLETION DATE
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|The date on which a clustering tool assessment was completed for a patient.
|R
|M
|
|
|-
|-
|NUMBER OF GROUP THERAPY PARTICIPANTS
|ASSESSMENT TOOL COMPLETION TIME
|The number of persons who participated in the Group Therapy, excluding the Care Professionals.
|The time on which a clustering tool assessment was completed for a patient.
|R
|R
|
|
|-
|-
|NUMBER OF GROUP THERAPY FACILITATORS
|CLUSTERING TOOL ASSESSMENT REASON
|The number of Care Professionals who facilitated the Group Therapy.
|The reason that the clustering tool assessment for the patient was undertaken.
|R
|R
|
|10 - Initial assessment
 
11 - Scheduled re-assessment
 
12 - Re-assessment following significant unanticipated change in need
 
97 - Other Reason (not listed)
 
99 - CLUSTERING TOOL ASSESSMENT REASON Not Known (Not Recorded)
|-
|-
|PSYCHOTROPIC MEDICATION USAGE INDICATION CODE
|MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE
|An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT.
|The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation.
|R
|R
|
|A - Non-Psychotic
 
B - Psychotic
 
C - Organic
 
Z - Unable to assign patient to Mental Health Care Cluster Super Class
|-
|-
|LANGUAGE CODE (TREATMENT)
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL)
|The language used for the delivery of treatment to the Patient.  LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions.
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm.
|R
|R
|
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
|-
 
|INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)
|An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter.
 
|R
02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)
|
 
|}
03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)
 
04 - Care Cluster 4 - Non-Psychotic (Severe)
 
05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)
 
06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas
 
07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)


=== Internet Ther Log ===
08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders
{| class="wikitable"
 
!Name
09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.
!Description
 
!Conformance
10 - Care Cluster 10 - First Episode Psychosis
!Value Set
 
|-
11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)
|START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
 
|The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)
|M
 
13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
14 - Care Cluster 14 - Psychotic Crisis
 
15 - Care Cluster 15 - Severe Psychotic Depression
 
16 - Care Cluster 16 - Dual Diagnosis
 
17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)
 
18 - Care Cluster 18 - Cognitive Impairment (Low Need)
 
19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)
 
20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)
 
21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)
|-
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|
|}
<br />
=== Care Cluster ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|-
|END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
|START DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
|The date on which the assignment of a patient to a Care Cluster started.
|M
|M
|
|
|-
|-
|INTERNET ENABLED THERAPY PROGRAMME
|START TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|The time on which the assignment of a patient to a Care Cluster started.
|M
|R
|
|
|-
|-
|DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period.
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm.
|M
|
|-
|INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR
|An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy.
|R
|R
|
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
|}
 
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)
 
02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)
 
03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)
 
04 - Care Cluster 4 - Non-Psychotic (Severe)


=== Medical History Previous Diagnosis ===
05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|DIAGNOSIS DATE
|DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS.
|R
|
|}


=== Long Term Condition ===
06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas
{| class="wikitable"
 
!Name
07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)
!Description
 
!Conformance
08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders
!Value Set
 
|-
09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.
|LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY)
 
|The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition.
10 - Care Cluster 10 - First Episode Psychosis
|M
 
|
11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)
|}
 
12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)
 
13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
14 - Care Cluster 14 - Psychotic Crisis
 
15 - Care Cluster 15 - Severe Psychotic Depression
 
16 - Care Cluster 16 - Dual Diagnosis
 
17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)
 
18 - Care Cluster 18 - Cognitive Impairment (Low Need)
 
19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)
 
20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)


=== Presenting Complaints ===
21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|PRESENTING COMPLAINT (CODED CLINICAL ENTRY)
|CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE
|The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL
|The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL.
|M
|
|-
|PRESENTING COMPLAINT CODING SIGNIFICANCE
|The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL.
|R
|R
|10 - Getting Advice: Neurodevelopmental Assessment (NEU)
11 - Getting Advice: Signposting and Self-management Advice (ADV)
12 - Getting Help: Attention Deficit Hyperactivity Disorder (ADHD)
13 - Getting Help: Autism (AUT)
14 - Getting Help: Behavioural and/or Conduct Disorders (BEH)
15 - Getting Help: Bipolar Disorder (BIP)
16 - Getting Help: Depression (DEP)
17 - Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP)
18 - Getting Help: Obsessive compulsive disorder (OCD)
19 - Getting Help: Post-traumatic stress disorder (PTS)
20 - Getting Help: Self-harm (SHA)
21 - Getting Help: Social Anxiety Disorder (SOC)
22 - Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM)
23 - Getting Help: Co-occurring Emotional Difficulties (EMO)
24 - Getting Help: Difficulties Not Covered by Other Groupings (DNC)
25 - Getting More Help: Eating Disorders (EAT)
26 - Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP)
27 - Getting More Help: Psychosis (PSY)
28 - Getting More Help: Difficulties of Severe Impact (DSI)
|-
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|
|-
|-
|PRESENTING COMPLAINT RECORDED DATE
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded.
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL.
|R
|00 - Care Cluster 0: Variance
 
01 - Care Cluster 1: Common Mental Health Problems (Low Severity)
 
02 - Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need)
 
03 - Care Cluster 3: Non-Psychotic (Moderate Severity)
 
04 - Care Cluster 4: Non-Psychotic (Severe)
 
05 - Care Cluster 5: Non-Psychotic Disorders (Very Severe)
 
06 - Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas
 
07 - Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability)
 
08 - Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders
 
08b - Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders
 
10 - Care Cluster 10: First Episode Psychosis
 
11 - Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms)
 
12 - Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability)
 
13 - Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
14 - Care Cluster 14: Psychotic Crisis
 
15 - Care Cluster 15: Severe Psychotic Depression
 
16 - Care Cluster 16: Dual Diagnosis
 
17 - Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage)
 
18 - Care Cluster 18: Cognitive Impairment (Low Need)
 
19 - Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need)
 
20 - Care Cluster 20: Cognitive Impairment or Dementia (High Need)
 
21 - Care Cluster 21: Cognitive Impairment or Dementia (High Physical or Engagement)
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|END DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|The date on which the assignment of a patient to a Care Cluster ended.
|R
|R
|
|
|}
|-
 
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
=== Care Cluster ===
|The time on which the assignment of a patient to a Care Cluster ended.
{| class="wikitable"
|R
!Name
|
!Description
|}
!Conformance
<br />
!Value Set
 
|-
=== Five Forensic Pathways ===
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
{| class="wikitable"
|The time on which the assignment of a patient to a Care Cluster ended.
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT DATE
|The date on which a Five Forensic Pathways assessment was completed for a patient.
|M
|
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT REASON
|The reason for which a Five Forensic Pathways assessment was undertaken.
|R
|10 - Initial Assessment
 
11 - Scheduled Re-Assessment
 
12 - Re-Assessment following significant unanticipated change in need
 
97 - Other Reason (not listed)
 
99 - Not Known (Not Recorded)
|-
|FIVE FORENSIC PATHWAYS CODE
|The Five Forensic Pathway assigned to a patient.
|M
|0 - Unable to assign patient to one of the five forensic pathways
 
1 - Treatment responsive group
 
2 - Treatment resistant group – challenging behaviour
 
3 - Treatment resistant group – continuing care
 
4 - Personality disorder group – prison transfer
 
5 - Personality disorder group – co-morbidity
|}
<br />
 
=== Care Professionals ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PROFESSIONAL REGISTRATION BODY CODE
|A code which identifies the PROFESSIONAL REGISTRATION BODY.
|R
|01 - General Chiropractic Council
 
02 - General Dental Council
 
03 - General Medical Council
 
04 - General Optical Council
 
05 - Social Care Wales
 
08 - Health and Care Professions Council
 
09 - Nursing and Midwifery Council
 
16 - General Pharmaceutical Council
 
17 - General Osteopathic Council
 
18 - Social Work England
|-
|PROFESSIONAL REGISTRATION ENTRY IDENTIFIER
|The registration identifier allocated by an ORGANISATION.
|R
|
|-
|CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|The staff group of a CARE PROFESSIONAL working in a Mental Health Service.
|R
|01 - Medical
 
02 - Nursing
 
03 - Psychology
 
04 - Primary Mental Health
 
05 - Child and Adolescent Psychotherapy
 
06 - Counselling
 
07 - Family and Systemic Psychotherapy
 
08 - Occupational Therapy
 
09 - Social Work
 
10 - Creative Therapy
 
11 - Other Therapy (Qualified)
 
12 - Education
 
13 - Speech and Language Therapy
 
97 - Other (Qualified)
 
98 - Other (Unqualified)
|-
|MAIN SPECIALTY CODE (MENTAL HEALTH)
|The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period.
|R
|600 - General Medical Practice
 
700 - Learning Disability
 
710 - Adult Mental illness
 
711 - Child and Adolescent Psychiatry
 
712 - Forensic Psychiatry
 
713 - Medical Psychotherapy
 
715 - Old age psychiatry
 
950 - Nursing
 
960 - Allied Health Professional
|-
|OCCUPATION CODE
|An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual.
|R
|
|-
|CARE PROFESSIONAL (JOB ROLE CODE)
|A National Code for a POSITION applicable to an EMPLOYEE.
|R
|
|}<br />
== IAPT ==
<br />
 
=== Data Linkage ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system.
|M
|
|}
 
=== Header ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DATA SET VERSION NUMBER
|The version of the data set that this submission file is for.
|M
|
|-
|ORGANISATION IDENTIFIER (CODE OF PROVIDER)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database
|M
|
|-
|ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation.
|M
|
|-
|PRIMARY DATA COLLECTION SYSTEM IN USE
|The name of the Primary Data Collection System in use by the Health Care Provider.
|M
|
|-
|REPORTING PERIOD START DATE
|The reporting period start date to which this file refers
|M
|
|-
|REPORTING PERIOD END DATE
|The reporting period end date to which this file refers
|M
|
|-
|DATE AND TIME DATE SET CREATED
|Date/time this upload file was created
|M
|
|}
 
=== MPI ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The type of Educational Establishment that the student is attending.
|R
|1 - School
 
2 - College
 
3 - University
 
4 - Other Educational Establishment not listed
 
8 - Not applicable (Patient is not a student)
 
Z - Not stated (Patient asked but declined to provide a response)
 
X - Not Known (Not Recorded)
|}
 
=== Employment Status ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SELF EMPLOYED INDICATOR
|'An indication of whether an employed person is self-employed.
|R
|Y - Yes - Employed as a self-employed worker
 
N - No - Not self employed
 
8 - Not Applicable (Person is unemployed)
 
Z - Not stated (Person asked but declined to provide a response)
|-
|SICKNESS ABSENCE INDICATOR
|'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness.
|R
|Y - Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness
 
N - No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness
 
8 - Not Applicable (The person is unemployed)
 
Z - Not stated (Person asked but declined to provide a response)
 
X - Not Known (Not Recorded)
|-
|STATUTORY SICK PAY RECEIPT INDICATOR
|'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON.
|R
|Y - Yes - the person is currently in receipt of Statutory Sick Pay
 
N - No - the person is currently not in receipt of Statutory Sick Pay
 
U - Unknown (Person asked and does not know or is not sure)
 
Z - Not stated (Person asked but declined to provide a response)
|-
|BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|'An indication of whether a patient is currently receiving benefits, as stated by the patient.
|R
|Y - Yes - the PATIENT is currently in receipt of a benefit
 
N - No - the PATIENT is not currently in receipt of a benefit
 
U - Unknown (Person asked and does not know or is not sure)
 
Z - Not stated (Person asked but declined to provide a response)
|-
|EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient.
|R
|Y - Yes - receiving Employment and Support Allowance
 
N - No - not receiving Employment and Support Allowance
 
U - Unknown (Patient asked and does not know or is not sure)
 
Z - Not stated (Patient asked but declined to provide a response)
|-
|UNIVERSAL CREDIT RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient.
|R
|Y - Yes - receiving Universal Credit
 
N - No - not receiving Universal Credit
 
U - Unknown (Patient asked and does not know or is not sure)
 
Z - Not stated (Patient asked but declined to provide a response)
|-
|PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient.
|R
|Y - Yes - receiving Personal Independence Payment
 
N - No - Not receiving Personal Independence Payment
 
U - Unknown (Patient asked and does not know or is not sure)
 
Z - Not stated (Patient asked but declined to provide a response)
|-
|EMPLOYMENT SUPPORT SUITABILITY INDICATOR
|'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support.
|R
|Y - Yes - the patient is a suitable candidate for referral to Employment Support
 
N - No - the patient is not a suitable candidate for referral to Employment Support
 
N/A - Not Applicable
|-
|EMPLOYMENT SUPPORT REFERRAL DATE
|The date the PATIENT was referred for Employment Support.
|R
|
|}<br />
 
=== Social & Personal Circumstances ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE
|
|R
|
|}<br />
=== Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES
|The source of referral to a Mental Health Service.
|R
|A1 - Primary Health Care: General Medical Practitioner Practice
 
A2 - Primary Health Care: Health Visitor
 
A3 - Other Primary Health Care
 
A4 - Primary Health Care: Maternity Service
 
B1 - Self Referral: Self
 
B2 - Self Referral: Carer/Relative
 
C1 - Local Authority and Other Public Services: Social Services
 
C2 - Local Authority and Other Public Services: Education Service / Educational Establishment
 
C3 - Local Authority and Other Public Services: Housing Service
 
D1 - Employer
 
D2 - Employer: Occupational Health
 
E1 - Justice System: Police
 
E2 - Justice System: Courts
 
E3 - Justice System: Probation Service
 
E4 - Justice System: Prison
 
E5 - Justice System: Court Liaison and Diversion Service
 
E6 - Justice System: Youth Offending Team
 
F1 - Child Health: School Nurse
 
F2 - Child Health: Hospital-based Paediatrics
 
F3 - Child Health: Community-based Paediatrics
 
G1 - Independent sector - Medium Secure Inpatients
 
G2 - Independent Sector - Low Secure Inpatients
 
G3 - Other Independent Sector Mental Health Services
 
G4 - Voluntary Sector
 
H1 - Acute Secondary Care: Emergency Care Department
 
H2 - Other secondary care specialty
 
I1 - Temporary transfer from another Mental Health NHS Trust
 
I2 - Permanent transfer from another Mental Health NHS Trust
 
M1 - Other: Asylum Services
 
M2 - Other: Telephone or Electronic Access Service
 
M3 - Other: Out of Area Agency
 
M4 - Other: Drug Action Team / Drug Misuse Agency
 
M5 - Other: Jobcentre Plus
 
M6 - Other SERVICE or agency
 
M7 - Other: Single Point of Access Service
 
M8 - Debt agency
 
N1 - Stepped up from low intensity Improving Access to Psychological Therapies Service
 
N2 - Stepped down from high intensity Improving Access to Psychological Therapies Service
 
N4 - Other Improving Access to Psychological Therapies Service
 
P1 - Internal Referral
 
Q1 - Mental Health Drop In Service
|-
|YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT.
|R
|
|-
|PREVIOUS DIAGNOSED CONDITION INDICATOR
|An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT.
|R
|Y - Yes - this is a recurrence of a previously diagnosed condition
 
N - No - this is not a recurrence of a previously diagnosed condition
 
U - Unknown (Patient asked and does not know or is unsure)
 
Z - Not stated (Patient asked but declined to provide a response)
|-
|DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON
|The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service.
|R
|'''Referred but not seen'''
 
50 - Not assessed
 
 
'''Seen but not taken on for a course of treatment'''
 
10 - Not suitable for IAPT service - no action taken or directed back to referrer
 
11 - Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient
 
12 - Discharged by mutual agreement following advice and support
 
13 - Referred to another therapy service by mutual agreement
 
14 - Suitable for IAPT service, but patient declined treatment that was offered
 
16 - Incomplete Assessment (Patient dropped out)
 
17 - Deceased (Seen but not taken on for a course of treatment)
 
95 - Not Known (Seen but not taken on for a course of treatment)
 
 
'''Seen and taken on for a course of treatment'''
 
46 - Mutually agreed completion of treatment
 
47 - Termination of treatment earlier than Care Professional planned
 
48 - Termination of treatment earlier than patient requested
 
49 - Deceased (Seen and taken on for a course of treatment)
 
96 - Not Known (Seen and taken on for a course of treatment)
|-
|SERVICE DISCHARGE DATE
|The date a PATIENT was discharged from a SERVICE.
|R
|
|}
 
=== Onward Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The reason why the patient was referred from one service to another service, which may be in the same or a different organisation.
|R
|1 - Transfer of Clinical Responsibility
 
2 - For Opinion Only
 
3 - For Diagnostic Test Only
 
4 - New Referral (Non Transfer)
 
5 - Stepped up from low intensity Improving Access to Psychological Therapies Service
 
6 - Stepped down from high intensity Improving Access to Psychological Therapies Service
 
96 - Other (not listed)
 
98 - Onward Referral Reason Not Applicable
 
99 - Not Known (Not Recorded)
|}
 
=== Waiting Time Pauses ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER
|The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION.
|M
|
|-
|ACTIVITY SUSPENSION START DATE
|The date on which the break from the ACTIVITY starts.
|M
|
|-
|ACTIVITY SUSPENSION END DATE
|The date on which the break from the ACTIVITY ends.
|R
|
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON
|The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set.  Patient Initiated pause in the waiting period.
|R
|1 - Patient unavailable due to holiday
 
2 - Patient unavailable due to other health needs
 
3 - Patient stated not available - other reason (not listed)
|}
 
=== Care Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR
|An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice.
|R
|Y - Yes - Appointment slot could be reallocated
 
N - No - Appointment slot could not be reallocated
|-
|INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR
|An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service.
|M
|Y - Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological
 
Therapies Long Term Condition Service
 
N - No - the Improving Access to Psychological Therapies Contact was not provided by an Integrated Improving Access to Psychological
 
Therapies Long Term Condition Service
|-
|APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The type of Improving Access to Psychological Therapies APPOINTMENT.
|M
|1 - Assessment
 
2 - Treatment
 
3 - Assessment and treatment
 
4 - Review only
 
5 - Review and treatment
 
6 - Follow-up appointment after treatment end
 
10 - Employment Support
 
98 - Other (not listed)
 
99 - Not Known (Not Recorded)
|-
|INTERNET ENABLED THERAPY PROGRAMME
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|R
|
|-
|NUMBER OF GROUP THERAPY PARTICIPANTS
|The number of persons who participated in the Group Therapy, excluding the Care Professionals.
|R
|
|-
|NUMBER OF GROUP THERAPY FACILITATORS
|The number of Care Professionals who facilitated the Group Therapy.
|R
|
|-
|PSYCHOTROPIC MEDICATION USAGE INDICATION CODE
|An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT.
|R
|1 - Prescribed but not taking
 
2 - Prescribed and taking
 
3 - Not Prescribed
 
UU - Unknown (Patient asked and does not know or is not sure)
 
ZZ - Not stated (Patient asked but declined to provide a response)
|-
|LANGUAGE CODE (TREATMENT)
|The language used for the delivery of treatment to the Patient.  LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions.
|R
|'''All Spoken Languages'''
 
- ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki>
 
 
'''Extensions'''
 
q1 - Braille (for people who are unable to see)
 
q2 - American Sign Language
 
q3 - Australian Sign Language
 
q4 - British Sign Language
 
q5 - Makaton (devised for children and adults with a variety of communication and Learning Disabilities)
|-
|INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE
|An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter.
|R
|1 - Yes - Professional interpreter
 
2 - Yes - Family member or friend
 
3 - Yes - Another Person
 
4 - No - Interpreter not required
 
5 - No - Interpreter was required but did not attend
 
X - Not Known (Not Recorded)
|}
 
=== Internet Therapy Log ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
|The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
|M
|
|-
|END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
|The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
|M
|
|-
|INTERNET ENABLED THERAPY PROGRAMME
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|M
|
|-
|DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME
|The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period.
|M
|
|-
|INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR
|An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy.
|R
|Y - Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy
 
N - No - an Internet Enabled Therapy Integrated Software Engine was not used as part of Internet Enabled Therapy
|}
 
=== Medical History Previous Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DIAGNOSIS DATE
|DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS.
|R
|
|}
 
=== Long Term Condition ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY)
|The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition.
|M
|
|}
 
=== Presenting Complaints ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PRESENTING COMPLAINT (CODED CLINICAL ENTRY)
|The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL
|M
|
|-
|PRESENTING COMPLAINT CODING SIGNIFICANCE
|The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL.
|R
|1 - Primary Presenting Complaint
 
2 - Secondary Presenting Complaint
|-
|PRESENTING COMPLAINT RECORDED DATE
|The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded.
|R
|
|}
 
=== Care Cluster ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The time on which the assignment of a patient to a Care Cluster ended.
|R
|
|}
 
=== Care Personnel Qualification ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|M
|
|-
|QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The qualification or individual accreditation attained or planned to be attained, by the Care Personnel.
|M
|10 - Curriculum for Psychological Wellbeing Practitioners (PWP)
 
11 - Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT)
 
12 - Curriculum for Counselling for Depression (CfD)
 
13 - Curriculum for Couple Therapy for Depression
 
(CTfD) / Curriculum for Behavioural Couples
 
Therapy (BCT) for Depression
 
14 - Curriculum for Dynamic
 
Interpersonal Therapy (DIT) for Depression
 
15 - Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT)
 
16 - Curriculum for Mindfulness-based Cognitive Therapy (MBCT)
 
17 - Curriculum for Eye Movement Desensitisation Reprocessing (EMDR)
 
30 - Curriculum for Employment Advisers
 
31 - Curriculum for Senior Employment Advisers
|-
|EMPLOYEE QUALIFICATION AWARDED DATE
|The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course.
|R
|
|-
|EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE
|The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying.
|R
|R
|
|
|}
|}


=== Care Personnel Qualification ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|M
|
|-
|QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The qualification or individual accreditation attained or planned to be attained, by the Care Personnel.
|M
|
|-
|EMPLOYEE QUALIFICATION AWARDED DATE
|The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course.
|R
|
|-
|EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE
|The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying.
|R
|
|}


=== Freeform Placeholder ===
== Freeform Placeholder ==
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!Value Set
!Codes & Primary Value Set
|-
|-
|FREEFORM NOTES
|FREEFORM NOTES

Latest revision as of 11:45, 15 February 2023

MHSDS


Master Patient Index

Name Description Conformance Codes & Primary Value Set
LOCAL PATIENT IDENTIFIER (EXTENDED) This is a number used to identify a PATIENT uniquely within a Health Care Provider. It may be different from the PATIENT's casenote number and may be assigned automatically by the computer system. LOCAL PATIENT IDENTIFIER (EXTENDED) is used where IT systems have a LOCAL PATIENT IDENTIFIER which is longer than 10 characters and LOCAL PATIENT IDENTIFIER cannot be used for data submission. M
ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER) The ORGANISATION IDENTIFIER of the organisation that assigned the local patient identifier. M
ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) is the ORGANISATION IDENTIFIER of the Educational Establishment, including Schools. R
NHS NUMBER A number used to identify a PATIENT uniquely within the NHS in England and Wales R
NHS NUMBER STATUS INDICATOR CODE (MENTAL HEALTH AND MATERNITY) The NHS NUMBER STATUS INDICATOR of the PATIENT R 01- Number present and verified

02- Number present but not traced

03- Trace required

04- Trace attempted - No match or multiple match found

05- Trace needs to be resolved - (NHS Number or patient detail conflict)

06- Trace in progress

07- Number not present and trace not required

PERSON BIRTH DATE The date on which a PERSON was born or is officially deemed to have been born R
POSTCODE OF USUAL ADDRESS The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence' R
GENDER IDENTITY CODE The gender identity of a PERSON as stated by the PERSON R 1- Male (including trans man)

2- Female (including trans woman)

3- Non-binary

4- Other (not listed)

X- Not Known (not recorded)

Z- Not Stated (person asked but declined to provide a response)

GENDER IDENTITY SAME AT BIRTH INDICATOR An indication of whether the patient's gender identity is the same as their gender assigned at birth. R Y- Yes - the person's gender identity is the same as their gender assigned at birth

N- No - the person's gender identity is not the same as their gender assigned at birth

X- Not Known (not asked)

Z- Not Stated (person asked but declined to provide a response)

PERSON STATED GENDER CODE The gender of a PERSON.
PERSON STATED GENDER CODE is self declared or inferred by observation for those unable to declare their PERSON STATED GENDER. 		R 1- Male

2- Female

9- Indeterminate (unable to be classified as either male or female)

X- Not Known (PERSON STATED GENDER CODE not recorded)

PERSON MARITAL STATUS The legal marital status of a PERSON. R S- Single

M- Married/Civil Partner

D- Divorced/Person whose Civil Partnership has been dissolved

W- Widowed/Surviving Civil Partner

P- Separated

N- Not disclosed

8- Not applicable

9- Not known

ETHNIC CATEGORY The ethnicity of a PERSON, as specified by the PERSON. R A- White - British

B- White - Irish

C- White - Any other White background

D- Mixed - White and Black Caribbean

E- Mixed - White and Black African

F- Mixed - White and Asian

G- Mixed - Any other mixed background

H- Asian or Asian British - Indian

J- Asian or Asian British - Pakistani

K- Asian or Asian British - Bangladeshi

L- Asian or Asian British - Any other Asian background

M- Black or Black British - Caribbean

N- Black or Black British - African

P- Black or Black British - Any other Black background

R- Other Ethnic Groups - Chinese

S- Other Ethnic Groups - Any other ethnic group

Z- Not stated

99- Not known

ETHNIC CATEGORY 2021 Placeholder data item to accommodate the 2021 census when it goes live P
LANGUAGE CODE (PREFERRED) LANGUAGE CODE (PREFERRED) is the language the PATIENT prefers to use for communication with a Health Care Provider. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions. R All Spoken Languages

ISO 639-1 codes at http://www.loc.gov/standards/iso639-2/php/code_list.php

Extensions

q1- Braille (for people who are unable to see)

q2- American Sign Language

q3- Australian Sign Language

q4- British Sign Language

q5- Makaton (devised for children and adults with a variety of communication and Learning Disabilities)

PERSON DEATH DATE The date on which a person died or is officially deemed to have died, as recorded on the death certificate. R


GP Practice Registration

Name Description Conformance Codes & Primary Value Set
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) The ORGANISATION CODE of the GP Practice that the PATIENT is registered with. M
START DATE (GMP PATIENT REGISTRATION) Start Date on which the PERSON registered with a General Medical Practitioner Practice. R
END DATE (GMP PATIENT REGISTRATION) The DATE on which the PERSON ceased to be registered with a General Medical Practitioner Practice. R


Accommodation Status

Name Description Conformance Codes & Primary Value Set
ACCOMMODATION TYPE An indication of the type of accommodation that a PATIENT currently has. This should be based on the PATIENT's main or permanent residence. M 01- Owner occupier

02- Tenant - Local Authority/Arms Length Management Organisation/registered social housing provider

03- Tenant - private landlord

04- Living with family

05- Living with friends

06- University or College accommodation

07- Accommodation tied to job (including Armed Forces)

08- Mobile accommodation

09- Care home without nursing

10- Care home with nursing

11- Specialist Housing (with suitable adaptations to meet impairment needs and support to live independently)

12- Rough sleeper

13- Squatting

14- Sofa surfing (sleeps on different friends floor each night)

15- Staying with friends/family as a short term guest

16- Bed and breakfast accommodation to prevent or relieve homelessness

17- Sleeping in a night shelter

18- Hostel to prevent or relieve homelessness

19- Temporary housing to prevent or relieve homelessness

20- Admitted patient settings

21- Criminal justice settings

98- Other (not listed)

SETTLED ACCOMMODATION INDICATOR An indication of whether the main/permanent residence of the patient is settled accommodation. R Y- Yes - Settled Accommodation

N- No - Non-settled Accommodation

Z- Not Stated (PATIENT asked but declined to provide a response)

9- Not known (Not Recorded)

ACCOMMODATION TYPE RECORDED DATE The PERSON PROPERTY RECORDED DATE when the ACCOMMODATION TYPE was recorded. R
SECURE CHILDRENS HOME PLACEMENT TYPE The type of placement for a child or young person accommodated in a Secure Children's Home. R 1- Secure welfare placement

2- Youth justice placement

ACCOMMODATION TYPE START DATE The date that the patient's accommodation type started. R
ACCOMMODATION TYPE END DATE The date that the patient's accommodation type ended. R


Employment Status

Name Description Conformance Codes & Primary Value Set
EMPLOYMENT STATUS The current PRIMARY EMPLOYMENT status of a PERSON. M 01- Employed

02- Unemployed and actively seeking work

03- Undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training as a student and not working or actively seeking work

04- Long-term sick or disabled, those receiving government sickness and disability benefits

05- Looking after the family or home as a homemaker and not working or actively seeking work

06- Not receiving government sickness and disability benefits and not working or actively seeking work

07- Unpaid voluntary work and not working or actively seeking work

08- Retired

ZZ- Not Stated (PERSON asked but declined to provide a response)

EMPLOYMENT STATUS START DATE The date that the patient's employment status started. R
EMPLOYMENT STATUS END DATE The date that the patient's employment status ended. R
EMPLOYMENT STATUS RECORDED DATE The date that the patient's employment status details were recorded by the healthcare professional. R
WEEKLY HOURS WORKED The number of hours worked in a typical week. R 01- 30+ hours

02- 16-29 hours

03- 5-15 hours

04- 1-4 hours

97- Not Stated (PERSON asked but declined to provide a response)

98- Not applicable (PERSON not employed)

99- Number of hours worked not known


Patient Indicators

Name Description Conformance Codes & Primary Value Set
CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing. R Y - Yes: PATIENT requires constant care and/or supervision


N - No: PATIENT does not require constant care and/or supervision

PARENTAL RESPONSIBILITIES INDICATOR An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT. R Y - Yes: PATIENT has parental responsibilities for a child or young person


N - No: PATIENT does not have parental responsibilities for a child or young person


Z - Not Stated (PATIENT asked but declined to provide a response)


X - Not Known (not recorded)

YOUNG CARER INDICATOR An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling. R Y - Yes: PATIENT has a caring role for an ill or disabled parent, Carer or sibling


N - No: PATIENT does not have a caring role for an ill or disabled parent, Carer or sibling


Z.- Not Stated: (PATIENT asked but declined to provide a response)


X.- Not known whether the PATIENT is a young Carer

LOOKED AFTER CHILD INDICATOR An indication of whether a PATIENT is a Looked After Child. R Yes - is a Looked After Child


No - is not a Looked After Child

Not Known if the PATIENT is a Looked After Child

LOOKED AFTER CHILD LEGAL STATUS The legal status of the Looked After Child. This refers to the Children's Act 1989: see details https://www.legislation.gov.uk/ukpga/1989/41/contents R 01 - Section 20 Voluntary Agreement


02 = Section 31 Care Order


03 = Section 38 Interim Care Order


08 = Other (not listed)

EDUCATIONAL ASSESSMENT OUTCOME The outcome of an EDUCATIONAL ASSESSMENT. R 01 - No Special Education Needs

05 - Subject to Education, Health and Care Plan (EHC)

CHILD PROTECTION PLAN INDICATION CODE An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan. R 1 - Has never been subject to a Child Protection Plan

2 - Has previously been subject to a Child Protection Plan

3 - Is currently subject to a Child Protection Plan

X - Not Known whether the PATIENT is or has ever been the subject of a Child Protection Plan

EX-BRITISH ARMED FORCES INDICATOR An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member. R 02 - Ex-services member

03 - Not an ex-services member or their dependant

05 - Dependant of an ex-services member

UU - Unknown (PATIENT asked and does not know or is not sure)

ZZ - Not stated (PATIENT asked but declined to provide a response)

OFFENCE HISTORY INDICATION CODE An indication of whether the PATIENT has a history of offences, including index offences (i.e. is recordable, committed in England and Wales, prosecuted by the police and is not a breach of the peace).

This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information.

R 1 - No - No offence

2 - Yes - Less serious offence

3 - Yes - Serious offence

X - Not Known (Not Recorded)

PRODROME PSYCHOSIS DATE Date at which first noticeable change in behaviour or mental state occurred prior to emergence of full-blown psychosis for the patient. There should be a clear deterioration in functioning from previous levels.

Examples include poor attendance/worsening performance at school/work, trouble sleeping, withdrawing from/fighting with friends/family, attenuated psychotic symptoms (increased suspiciousness,/jealously, occasionally hearing name being called when no' ones around, whisperings, slight confusion in thinking etc.).

R
EMERGENT PSYCHOSIS DATE Date at which there was first clear evidence of a positive psychotic symptom for the patient (i.e. delusion, hallucination, or thought disorder), regardless of its duration.

Such a symptom would be scored 4 or more on the PANSS.

R
MANIFEST PSYCHOSIS DATE Date at which a positive psychotic symptom has lasted for a week for the patient. This is usually just 7 days after the date of the first psychotic symptom. R
FIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION) Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service. R
PSYCHOSIS FIRST TREATMENT START DATE Date the patient first commenced prescribed (not PRN) anti-psychotic medication, following referral into an Early Intervention in Psychosis (EIP) Service, and thereafter was compliant for at least 75% of the time during the subsequent month (using clinical judgement).

Note: For the majority of people this will be the same date as the date of prescription.

R
REASONABLE ADJUSTMENT REQUIRED INDICATOR An indicator to alert the clinician that this patient may need a reasonable adjustment made R Y - Yes - the patient requires a Reasonable Adjustment

N - No - the patient does not require a Reasonable Adjustment


Mental Health Care Coordinator

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) The start date of a Mental Health Care Coordinator Assignment Period for a patient. M
CARE PROFESSIONAL LOCAL IDENTIFIER A unique local CARE PROFESSIONAL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.


R
END DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) The end date of a Mental Health Care Coordinator Assignment Period for a patient. R
CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH) The type of service or team the Care Professional is associated with. R A01 Day Care Service

A02 Crisis Resolution Team/Home Treatment Service

A05 Primary Care Mental Health Service

A06 Community Mental Health Team - Functional

A07 Community Mental Health Team - Organic

A08 Assertive Outreach Team

A09 Community Rehabilitation Service

A10 General Psychiatry Service

A11 Psychiatric Liaison Service

A12 Psychotherapy Service

A13 Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis

A15 Young Onset Dementia Team

A16 Personality Disorder Service

A17 Memory Services/Clinic/Drop in service

A18 Single Point of Access Service

A19 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service

A21 Crisis Café/Safe Haven/Sanctuary Service

A22 Walk-in Crisis Assessment Unit Service

A23 Psychiatric Decision Unit Service

A24 Acute Day Service

A25 Crisis House Service

B01 Forensic Mental Health Service

B02 Forensic Learning Disability Service

C01 Autism Service

C02 Specialist Perinatal Mental Health Community Service

C04 Neurodevelopment Team

C05 Paediatric Liaison Service

C06 Looked After Children Service

C07 Youth Offending Service

C08 Acquired Brain Injury Service

C10 Community Eating Disorder Service

D01 Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service

D04 Asylum Service

D05 Individual Placement and Support Service

D06 Mental Health In Education Service

D07 Problem Gambling Service

D08 Rough Sleeping Service

E01 Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service

E03 Specialist Parenting Service

E04 Enhanced/Intensive Support Service

F01 Mental Health Support Team

F02 Maternal Mental Health Service

F03 Mental Health Services for Deaf people

F04 Veterans Complex Treatment Service

F05 Enhanced care in care homes teams

F06 Mental Health and Wellbeing Hubs

Z01 Other Mental Health Service - in scope of National Tariff Payment System

Z02 Other Mental Health Service - out of scope of National Tariff Payment System


DisabilityType

Name Description Conformance Codes & Primary Value Set
DISABILITY CODE The DISABILITY of a PERSON.

This could be where:

the PERSON has been diagnosed as disabled or

the PERSON considers themself to be disabled.

M 01 Behaviour and Emotional

02 Hearing

03 Manual Dexterity

04 Memory or ability to concentrate, learn or understand (Learning Disability)

05 Mobility and Gross Motor

06 Perception of Physical Danger

07 Personal, Self Care and Continence

08 Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)

09 Sight

10 Speech

XX Other (not listed)

NN No Disability

ZZ Not Stated (Person asked but declined to provide a response)

DISABILITY IMPACT PERCEPTION The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months. R 01 - Yes – limited a lot

02 - Yes – limited a little

03 - No - not limited

04 - Prefer not to say (Patient asked but declined to provide a response)


Care Plan Type

Name Description Conformance Codes & Primary Value Set
CARE PLAN IDENTIFIER A unique identifierfor Care Plan. M
CARE PLAN TYPE (MENTAL HEALTH) The type of Care Plan for the patient, recorded by the service. M 10 - Mental Health Care Plan

11 - Urgent and Emergency Mental Health Care Plan

12 - Mental Health Crisis Plan

13 - Positive Behaviour Support Plan

14 - Child or Young Person's Mental Health Transition Plan

CARE PLAN CREATION DATE The date that a Care Plan was created for a patient. M
CARE PLAN CREATION TIME The time that a Care Plan was created for a patient. R
CARE PLAN LAST UPDATED DATE The date that the Care Plan was last updated for a patient.

Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date.

R
CARE PLAN LAST UPDATED TIME The time that the Care Plan was last updated for a patient.

Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time.

R
CARE PLAN IMPLEMENTATION DATE The date that the Care Plan was implemented for a patient. R


Care Plan Agreement

Name Description Conformance Codes & Primary Value Set
FAMILY INVOLVED IN CARE PLAN INDICATOR An indication of whether a member of the patient's family is currently involved in the patient's care plan.

This only needs to be captured for inpatients that are in scope of Transforming Care.

R Y - Yes - a member of the patient's family is currently involved in the patient's care plan

N - No - a member of the patient's family is not currently involved in the patient's care plan

9 - Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN

FAMILY NOT INVOLVED IN CARE PLAN REASON The reason that the patient's family is not currently involved in the patient's care plan.

This only needs to be captured for inpatients that are in scope of Transforming Care.

R 01 - At the request of the patient

02 - Access restrictions on the family

03 - No known family

08 - Other (not listed)

CARE PLAN CONTENT AGREED BY The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT. M Patient or Patient Proxy

Advocate

Clinical Service or Team

Local Community Support Team

Commissioner

Family member or carer with parental responsibility

Family member or carer without parental responsibility

CARE PLAN CONTENT AGREED DATE The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy. R 10 - Patient or Patient Proxy

12 - Advocate

13 - Clinical Service or Team

14 - Local Community Support Team

15 - Commissioner

16 - Family member or carer with parental responsibility

17 - Family member or carer without parental responsibility

CARE PLAN CONTENT AGREED TIME The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy R


Assistive Technology to Support Disability Type

Name Description Conformance Codes & Primary Value Set
ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on. M
PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY) The date, time and time zone for the prescription of Assistive Technology. R


Social and Personal Circumstances

Name Description Conformance Codes & Primary Value Set
SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person. M
SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP The date, time and time zone on which the Social and Personal Circumstance was recorded. R


Overseas Visitor Charging Category

Name Description Conformance Codes & Primary Value Set
OVERSEAS VISITOR CHARGING CATEGORY The charging category relating to an OVERSEAS VISITOR STATUS. M A - Standard NHS-funded PATIENT

B - Immigration Health Surcharge payee

C - Charge-exempt Overseas Visitor (European Economic Area)

D - Chargeable European Economic Area PATIENT

E - Charge-exempt Overseas Visitor (non-European Economic Area)

F - Chargeable non-European Economic Area PATIENT

P - Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY

9 - OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded)

OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded. R
OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until. R


Mental Health Currency Model

Name Description Conformance Codes & Primary Value Set
MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT) The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type. P
START DATE (MENTAL HEALTH RESOURCE GROUP) When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group P
END DATE (MENTAL HEALTH RESOURCE GROUP) When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service. P


Service or Team Referral

Name Description Conformance Codes & Primary Value Set
SERVICE REQUEST IDENTIFIER The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned. M
ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care. M
REFERRAL REQUEST RECEIVED DATE This is the date the REFERRAL REQUEST was received by the Health Care Provider. M
REFERRAL REQUEST RECEIVED TIME This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care. R
NHS SERVICE AGREEMENT LINE NUMBER A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES. R
SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements. R
SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET The source of referral to a Mental Health Service. R A1 - Primary Health Care: General Medical Practitioner Practice

A2 - Primary Health Care: Health Visitor

A3 - Other Primary Health Care

A4 - Primary Health Care: Maternity Service

B1 - Self-Referral: Self

B2 - Self-Referral: Carer/Relative

C1 - Local Authority and Other Public Services: Social Services

C2 - Local Authority and Other Public Services: Education Service / Educational Establishment

C3 - Local Authority and Other Public Services: Housing Service

D1 - Employer

D2 - Employer: Occupational Health

E1 - Justice System: Police

E2 - Justice System: Courts

E3 - Justice System: Probation Service

E4 - Justice System: Prison

E5 - Justice System: Court Liaison and Diversion Service

E6 - Justice System: Youth Offending Team

F1 - Child Health: School Nurse

F2 - Child Health: Hospital-based Paediatrics

F3 - Child Health: Community-based Paediatrics

G1 - Independent sector - Medium Secure Inpatients

G2 - Independent Sector - Low Secure Inpatients

G3 - Other Independent Sector Mental Health Services

G4 - Voluntary Sector

H1 - Acute Secondary Care: Emergency Care Department

H2 - Other secondary care specialty

I1 - Temporary transfer from another Mental Health NHS Trust

I2 - Permanent transfer from another Mental Health NHS Trust

M1 - Other: Asylum Services

M2 - Other: Telephone or Electronic Access Service

M3 - Other: Out of Area Agency

M4 - Other: Drug Action Team / Drug Misuse Agency

M5 - Other: Jobcentre Plus

M6 - Other SERVICE or agency

M7 - Other: Single Point of Access Service

M9 - Other: Urgent and Emergency Care Ambulance Service

N3 - Improving Access to Psychological Therapies Service

P1 - Internal Referral

Q1 - Mental Health Drop In Service

ORGANISATION IDENTIFIER (REFERRING) The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust. R
REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer. R A01 Art Therapist

A02 Clinical Psychologist

A03 Dietitian

A04 Dramatherapist

A05 Music Therapist

A06 Occupational Therapist

A07 Orthotist

A08 Physiotherapist

A09 Podiatrist

A10 Prosthetist

A11 Psychotherapist

A12 Radiographer

A13 Speech and Language Therapist

A14 Orthoptist

M01 Community Dentist

M02 Consultant

M03 General Medical Practitioner

M04 General Practitioner with an Extended Role (GPwER)

N01 Midwife

N02 District Nurse

N03 Health Visitor

N04 Macmillan Nurse

N05 School Nurse

N06 Specialist Nursing - Active Case Management (Community Matrons)

N07 Specialist Nursing - Arthritis Nursing/Liaison

N08 Specialist Nursing - Asthma and Respiratory Nursing/Liaison

N09 Specialist Nursing - Breast Care Nursing/Liaison

N10 Specialist Nursing - Cancer Related

N11 Specialist Nursing - Cardiac Nursing/Liaison

N12 Specialist Nursing - Children's Services

N13 Specialist Nursing - Community Cystic Fibrosis

N14 Specialist Nursing - Continence Services

N15 Specialist Nursing - Diabetic Nursing/Liaison

N16 Specialist Nursing - Enteral Feeding Nursing Services

N17 Specialist Nursing - Haemophilia Nursing Services

N19 Specialist Nursing - Infectious Diseases

N20 Specialist Nursing - Intensive Care Nursing

N21 Specialist Nursing - Palliative/Respite Care

N22 Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison

N23 Specialist Nursing - Rehabilitation Nursing

N24 Specialist Nursing - Stoma Care Services

N25 Specialist Nursing - Tissue Viability Nursing/Liaison

N26 Specialist Nursing - Transplantation Patients Nursing Services

N27 Specialist Nursing - Treatment Room Nursing Services

N28 Specialist Nursing - Tuberculosis Specialist Nursing

N29 Specialist Nursing - Other Specialist Nursing

N30 Specialist Nursing - Safeguarding

N31 Practice Nursing

N32 Staff Nurse

N33 Other Registered Nurse

N34 Public Health Nurse

C01 Appliances Technician

C02 Audiologist

C03 Counsellor

C04 Nursery Nurse

C06 Play Therapist

C07 Social Worker

C08 Voluntary Care Worker

C09 Screener (in a National Screening Programme)

C99 Other Care Professional (not listed)

CLINICAL RESPONSE PRIORITY TYPE The clinical response priority of a SERVICE REQUEST. R 1 - Emergency

2 - Urgent/Serious

3 - Routine

4 - Very Urgent

PRIMARY REASON FOR REFERRAL (MENTAL HEALTH) This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service R 01 - (Suspected) First Episode Psychosis

02 - Ongoing or Recurrent Psychosis

03 - Bi polar disorder

04 - Depression

05 - Anxiety

06 - Obsessive compulsive disorder

07 - Phobias

08 - Organic brain disorder

09 - Drug and alcohol difficulties

10 - Unexplained physical symptoms

11 - Post-traumatic stress disorder

12 - Eating disorders

13 - Perinatal mental health issues

14 - Personality disorders

15 - Self harm behaviours

16 - Conduct disorders

18 - In crisis

19 - Relationship difficulties

20 - Gender Discomfort issues

21 - Attachment difficulties

22 - Self - care issues

23 - Adjustment to health issues

24 - Neurodevelopmental Conditions, excluding Autism

25 - Suspected Autism

26 - Diagnosed Autism

27 - Preconception perinatal mental health concern

28 - Gambling disorder

29 - Community Perinatal Mental Health Partner Assessment

30 - Behaviours that challenge due to a Learning Disability

REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH) The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES. R 10 - Unavailability of bed at referring organisation

11 - Safeguarding

12 - Offending restrictions

13 - Staff member or family/friend within the referring organisation

14 - Patient choice

15 - Patient away from home

99 - Not Known (Not Recorded)

DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT) The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient R
DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT) The time that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient R
DISCHARGE PLAN CREATION DATE The date that a Discharge Plan was created for a patient. R
DISCHARGE PLAN CREATION TIME The time that a Discharge Plan was created for a patient. R
DISCHARGE PLAN LAST UPDATED DATE The date that the Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Date. R
DISCHARGE PLAN LAST UPDATED TIME The time that a Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Time. R
SERVICE DISCHARGE DATE Service Discharge Date is the date a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral. R
SERVICE DISCHARGE TIME Service Discharge Time is the time a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral. R


Other Reason for Referral

Name Description Conformance Codes & Primary Value Set
OTHER REASON FOR REFERRAL (MENTAL HEALTH) The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service. M 1 - (Suspected) First Episode Psychosis

2 - Ongoing or Recurrent Psychosis

3 - Bi polar disorder

4 - Depression

5 - Anxiety

6 - Obsessive compulsive disorder

7 - Phobias

8 - Organic brain disorder

9 - Drug and alcohol difficulties

10 - Unexplained physical symptoms

11 - Post-traumatic stress disorder

12 - Eating disorders

13 - Perinatal mental health issues

14 - Personality disorders

15 - Self harm behaviours

16 - Conduct disorders

18 - In crisis

19 - Relationship difficulties

20 - Gender Discomfort issues

21 - Attachment difficulties

22 - Self - care issues

23 - Adjustment to health issues

24 - Neurodevelopmental Conditions, excluding Autism

25 - Suspected Autism

26 - Diagnosed Autism

27 - Preconception perinatal mental health concern

28 - Gambling disorder

29 - Community Perinatal Mental Health Partner Assessment

30 - Behaviours that challenge due to a Learning Disability


Service or Team Type Referred To

Name Description Conformance Codes & Primary Value Set
CARE PROFESSIONAL TEAM LOCAL IDENTIFIER A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. R
SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) The type of service or team within a Mental Health Service that a patient was referred to M A01 Day Care Service

A02 Crisis Resolution Team/Home Treatment Service

A05 Primary Care Mental Health Service

A06 Community Mental Health Team - Functional

A07 Community Mental Health Team - Organic

A08 Assertive Outreach Team

A09 Community Rehabilitation Service

A10 General Psychiatry Service

A11 Psychiatric Liaison Service

A12 Psychotherapy Service

A13 Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis

A15 Young Onset Dementia Team

A16 Personality Disorder Service

A17 Memory Services/Clinic/Drop in service

A18 Single Point of Access Service

A19 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service

A21 Crisis Café/Safe Haven/Sanctuary Service

A22 Walk-in Crisis Assessment Unit Service

A23 Psychiatric Decision Unit Service

A24 Acute Day Service

A25 Crisis House Service

B01 Forensic Mental Health Service

B02 Forensic Learning Disability Service

C01 Autism Service

C02 Specialist Perinatal Mental Health Community Service

C04 Neurodevelopment Team

C05 Paediatric Liaison Service

C06 Looked After Children Service

C07 Youth Offending Service

C08 Acquired Brain Injury Service

C10 Community Eating Disorder Service

D01 Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service

D04 Asylum Service

D05 Individual Placement and Support Service

D06 Mental Health In Education Service

D07 Problem Gambling Service

D08 Rough Sleeping Service

E01 Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service

E03 Specialist Parenting Service

E04 Enhanced/Intensive Support Service

F01 Mental Health Support Team

F02 Maternal Mental Health Service

F03 Mental Health Services for Deaf people

F04 Veterans Complex Treatment Service

F05 Enhanced care in care homes teams

F06 Mental Health and Wellbeing Hubs

Z01 Other Mental Health Service - in scope of National Tariff Payment System

Z02 Other Mental Health Service - out of scope of National Tariff Payment System

REFERRAL CLOSURE DATE The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. R
REFERRAL CLOSURE TIME The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. R
REFERRAL REJECTION DATE The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. R
REFERRAL REJECTION TIME The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. R
REFERRAL CLOSURE REASON The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set. R 01 - Admitted elsewhere (at the same or other Health Care Provider)

02 - Treatment completed

03 - Moved out of the area

04 - No further treatment appropriate

05 - Patient did not attend

06 - Patient died

07 - Patient requested discharge

08 - Referred to other specialty/Service (at the same or other Health Care Provider)

09 - PATIENT refused to be seen

REFERRAL REJECTION REASON The reason that a Referral Request has been rejected by the SERVICE. R 01 - Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider)

02 - Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider)

03 - Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST)


Referral to Treatment (RTT)

Name Description Conformance Codes & Primary Value Set
PATIENT PATHWAY IDENTIFIER An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY. R
ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER. R
WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH) The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy. M 02 - Allied Health Professional Referral To Treatment Measurement

09 - Other Referral To Treatment Measurement Type (not listed)

REFERRAL TO TREATMENT PERIOD START DATE The start date of a REFERRAL TO TREATMENT PERIOD. R
REFERRAL TO TREATMENT PERIOD END DATE The end date of a REFERRAL TO TREATMENT PERIOD. R
REFERRAL TO TREATMENT PERIOD STATUS The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL. R 10 - First activity in a Referral to Treatment Period

11 - First activity at the start of a new Referral to Treatment Period following Active Monitoring

12 - First activity at the start of a new Referral to Treatment Period following a decision to refer directly to the consultant or NHS Allied Health Professional Service (Referral To Treatment Measurement) for a separate condition

20 - Subsequent activity during a Referral to Treatment Period - further activities anticipated

21 - Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated

30 - End of the Referral to Treatment Period: Start of First Definitive Treatment

31 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient

32 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional

33 - End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral

34 - End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required

35 - End of the Referral to Treatment Period: patient declined offered treatment

36 - End of the Referral to Treatment Period: patient died before treatment

90 - Not part of a Referral to Treatment Period: After treatment - First Definitive Treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment)

91 - Not part of a Referral to Treatment Period: Care activity during Active Monitoring

92 - Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral

98 - Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods

99 - Referral to Treatment Period status not yet known


Onward Referral

Name Description Conformance Codes & Primary Value Set
DECISION TO REFER DATE (ONWARD REFERRAL) DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. R
DECISION TO REFER TIME (ONWARD REFERRAL) DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. R
ONWARD REFERRAL DATE The date the patient was referred to another service, which may be in the same or a different organisation. M
ONWARD REFERRAL TIME The time the patient was referred to another service, which may be in the same or a different organisation. R
ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET) The reason why the PATIENT was referred to another service, which may be in the same or a different organisation. R 01 - Transfer of Clinical Responsibility

02 - For Opinion Only

03 - For Diagnostic Test Only

04 - New Referral (Non Transfer)

96 - Other (not listed)

98 - Onward Referral Reason Not Applicable

99 - Not Known (Not Recorded)

REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH) The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy. R 10 - Unavailability of bed at referring organisation

11 - Safeguarding

12 - Offending restrictions

13 - Staff member or family/friend within the referring organisation

14 - Patient choice

99 - Not Known (Not Recorded)

ORGANISATION IDENTIFIER (RECEIVING) ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider. R
CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT) The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed. R


Discharge Plan Agreement

Name Description Conformance Codes & Primary Value Set
DISCHARGE PLAN CONTENT AGREED BY The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT. M 10 - Patient or Patient Proxy

12 - Advocate

13 - Clinical Service or Team

14 - Local Community Support Team

15 - Current Commissioner

16 - Commissioner of Planned Discharge Destination

17 - Family member or carer with parental responsibility

18 - Family member or carer without parental responsibility

DISCHARGE PLAN CONTENT AGREED DATE The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. R
DISCHARGE PLAN CONTENT AGREED TIME RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. R


Medication Prescription

Name Description Conformance Codes & Primary Value Set
PRESCRIPTION IDENTIFIER The unique identifier of a PRESCRIPTION. P
PRESCRIPTION DATE (MEDICATION) The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. P
PRESCRIPTION TIME (MEDICATION) The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. P


Care Contact

Name Description Conformance Codes & Primary Value Set
CARE CONTACT IDENTIFIER The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned. M
CARE PROFESSIONAL TEAM LOCAL IDENTIFIER A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. R
CARE CONTACT DATE The date on which a Care Contact took place, or, if cancelled, was scheduled to take place. M
CARE CONTACT TIME The time at which a Care Contact took place. R
ADMINISTRATIVE CATEGORY CODE This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed. R 01 - NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)

02 - Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006

03 - Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006

04 - Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff.

98 - Not applicable

99 - ADMINISTRATIVE CATEGORY CODE not known

CLINICAL CONTACT DURATION OF CARE CONTACT The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes. R
CONSULTATION TYPE The type of consultation between the CARE PROFESSIONAL and the PATIENT. R 01 - Initial Consultation

02 - Follow-up Consultation

CARE CONTACT SUBJECT The person who was the subject of the Care Contact. R 01 - Patient

02 - Patient Proxy

CONSULTATION MECHANISM (MENTAL HEALTH) The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS. R 01 - Face to face

02 - Telephone

04 - Talk type for a person unable to speak

05 - Email

09 - Text Message (Asynchronous)

10 - Instant messaging (Synchronous)

11 - Video consultation

12 - Message Board (Asynchronous)

13 - Chat Room (Synchronous)

98 - Other (not listed)

ACTIVITY LOCATION TYPE CODE The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent. R A01 Patient's home

A02 Carer's home

A03 Patient's workplace

A04 Other patient related location

B01 Primary Care Health Centre

B02 Polyclinic

C01 General Medical Practitioner Practice

C02 Dental Practice

C03 Ophthalmic Medical Practitioner premises

D01 Walk In Centre

D02 Out of Hours Centre

D03 Emergency Community Dental Service

E01 Out-Patient Clinic

E02 Ward

E03 Day Hospital

E04 Emergency Care Department or Minor Injuries Department

E99 Other departments

F01 Hospice

G01 Care Home Without Nursing

G02 Care Home With Nursing

G03 Children’s Home

G04 Integrated Care Home Without Nursing and Care Home With Nursing

H01 Day Centre

J01 Resource Centre

K01 Sure Start Children’s Centre

K02 Child Development Centre

L01 School

L02 Further Education College

L03 University

L04 Nursery Premises

L05 Other Childcare Premises

L06 Training Establishments

L99 Other Educational Premises

M01 Prison

M02 Probation Service Premises

M03 Police Station / Police Custody Suite

M04 Young Offender Institution

M06 Young Offender Institution (15-17)

M07 Young Offender Institution (18-21)

M05 Immigration Removal Centre

N01 Street or other public open space

N02 Other publicly accessible area or building

N03 Voluntary or charitable agency premises

N04 Dispensing Optician premises

N05 Dispensing Pharmacy premises

X01 Other locations not elsewhere classified

1 General Health Promotion Session

2 Telephone Support Sessiom

3 Thereputic Group Session

PLACE OF SAFETY INDICATOR An indication of whether a LOCATION is being used as a PLACE OF SAFETY. R Y - Yes – is being used as a Place of Safety

N - No – is not being used as a Place of Safety

ORGANISATION SITE IDENTIFIER (OF TREATMENT) The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated. R
COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service. R Y - Yes - a Community Perinatal Mental Health Partner Assessment has been offered

N - No - a Community Perinatal Mental Health Partner Assessment has not been offered

PLANNED CARE CONTACT INDICATOR An indication as to whether a Care Contact is a result of a Planned Appointment. R Y - Yes - the care contact is a result of a planned Appointment

N - No - the care contact is not a result of a planned appointment

CARE CONTACT PATIENT THERAPY MODE The mode of therapy for the patient during a Care Contact. R 1 - Individual patient

2 - Couple

3 - Group Therapy

ATTENDED OR DID NOT ATTEND CODE This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given. R 5 - Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT

6 - Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen

7 - Patient arrived late and could not be seen

2 - APPOINTMENT cancelled by, or on behalf of, the PATIENT

3 - Did not attend - no advance warning given

4 - Appointment cancelled or postponed by the health care provider

EARLIEST REASONABLE OFFER DATE The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission. R
EARLIEST CLINICALLY APPROPRIATE DATE The earliest DATE that it was clinically appropriate for an ACTIVITY to take place. R
CARE CONTACT CANCELLATION DATE The date that a Care Contact was cancelled by the Provider or Patient. R
CARE CONTACT CANCELLATION REASON The reason that a Care Contact was cancelled. R 01 - Cancelled for Clinical Reasons

02 - Cancelled for Non-clinical Reasons

REASONABLE ADJUSTMENT MADE INDICATOR Was a reasonable adjustment made for this patient? R Y - Yes - a Reasonable Adjustment was made for the patient

N - No - a Reasonable Adjustment was not made for the patient

X - Not applicable


Care Activity

Name Description Conformance Codes & Primary Value Set
CARE ACTIVITY IDENTIFIER The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned. M
CLINICAL CONTACT DURATION OF CARE ACTIVITY The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY. R
CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. R
FINDING SCHEME IN USE (MENTAL HEALTH) The code scheme basis of a finding. R 01 - ICD-10

04 - SNOMED CT®

CODED FINDING (CODED CLINICAL ENTRY) A unique identifier for a finding from a specific classification or clinical terminology. R
CODED OBSERVATION (SNOMED CT) A unique identifier for an observation from a specific clinical terminology. R
OBSERVATION VALUE The numeric value resulting from a clinical observation. R
UCUM UNIT OF MEASUREMENT The unit of measurement used to measure the result of a clinical observation. See http://unitsofmeasure.org/trac/. R


Other in Attendance

Name Description Conformance Codes & Primary Value Set
OTHER PERSON IN ATTENDANCE AT CARE CONTACT The other PERSON in attendance, with the PATIENT, at the CARE CONTACT. M 01 - Independent Advocate (Family Member)

02 - Independent Advocate (Independent Person)

03 - Independent Mental Capacity Advocate (IMCA)

04 - Independent Mental Health Advocate (IMHA)

05 - Non-Instructed Advocate

10 - Parent or relative (Non-Advocate)

11 - Friend or neighbour (Non-Advocate)

12 - Care Worker (Non-Advocate)

REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care R 01 - PATIENT has chosen not to have an Independent Mental Health Advocate

02 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken

03 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought

04 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken

05 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought

98 - Other (not listed)

99 - Not applicable (no requirement for an Independent Mental Capacity Advocate)

REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care R 01 - Patient has chosen not to have an Independent Mental Health Advocate

02 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken

03 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought

04 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken

05 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought

98 - Other (not listed)

99 - Not applicable (no requirement for an Independent Mental Health Advocate)


Indirect Activity

Name Description Conformance Codes & Primary Value Set
INDIRECT ACTIVITY DATE The date that the indirect activity took place M
INDIRECT ACTIVITY TIME The time that the indirect activity took place R
DURATION OF INDIRECT ACTIVITY The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided. R
CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT) The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed. R


Group Session

Name Description Conformance Codes & Primary Value Set
GROUP SESSION IDENTIFIER The GROUP SESSION IDENTIFIER is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned. M
GROUP SESSION DATE The date that a Group Session took place, or, if cancelled, was scheduled to take place. M
CLINICAL CONTACT DURATION OF GROUP SESSION The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided. R
GROUP SESSION TYPE (MENTAL HEALTH) The type of Group Session provided by a Mental Health Service. R 01 - General Health Promotion Session

02 - Telephone Support Session

03 - Therapeutic Group Session

NUMBER OF GROUP SESSION PARTICIPANTS The number of persons who participated in the Group Session excluding the care professionals. R


Mental Health Drop In Contact

Name Description Conformance Codes & Primary Value Set
MENTAL HEALTH DROP IN CONTACT IDENTIFIER The Mental Health DROP IN CONTACT IDENTIFIER is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned. M
CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT) The date that a Drop In Contact took place. M
MENTAL HEALTH DROP IN CONTACT SERVICE TYPE The type of SERVICE where the Mental Health Drop In Contact took place. R A17 - Memory Services/Clinic/Drop In Service

A19 - 24/7 Crisis Response Line

A21 - Crisis Café/Safe Haven/Sanctuary Service

START TIME (MENTAL HEALTH DROP IN CONTACT) The Start Time of the Mental Health Drop In Contact as reported by the Care Professional. R
END TIME (MENTAL HEALTH DROP IN CONTACT) The End Time of the Mental Health Drop In Contact as reported by the Care Professional. R
MENTAL HEALTH DROP IN CONTACT OUTCOME The outcome of the Mental Health Drop In Contact as reported by the Care Professional. R 01 - Caller Disconnected

02 - Advice on call only

03 - Signposted to other non-NHS services sources of support

04 - Non-urgent referral to other NHS service

05 - Urgent referral for face to face assessment

06 - Emergency Service(s) notified

98 - Other (not listed)


Mental Health Act Legal Status Classification Assignment Period

Name Description Conformance Codes & Primary Value Set
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. M
START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) The Start Date of the Mental Health Act Legal Status Classification Assignment Period. M
START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) The Start Time of the Mental Health Act Legal Status Classification Assignment Period. M
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period. R 01 - Change in Mental Health Act Legal Status Classification Code (including from informal)

04 - Transfer from other Health Care Provider

EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. R
EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. R
END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) The date on which the Mental Health Act Legal Status Classification Assignment Period ended. R
END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) The time on which the Mental Health Act Legal Status Classification Period ended. R
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON The reason for the end of the Mental Health Act Legal Status Classification Assignment Period. R 01 - Change in Mental Health Act Legal Status Classification Code (including to informal)

04 - Transfer to other Health Care Provider

05 - Death of patient

MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE 'A code to identify the classification of Mental Health Act Legal Status. R 01 - Informal

02 - Formally detained under Mental Health Act Section 2

03 - Formally detained under Mental Health Act Section 3

04 - Formally detained under Mental Health Act Section 4

05 - Formally detained under Mental Health Act Section 5 (2)

06 - Formally detained under Mental Health Act Section 5 (4)

07 - Formally detained under Mental Health Act Section 35

08 - Formally detained under Mental Health Act Section 36

09 - Formally detained under Mental Health Act Section 37 with section 41 restrictions

10 - Formally detained under Mental Health Act Section 37

12 - Formally detained under Mental Health Act Section 38

13 - Formally detained under Mental Health Act Section 44

14 - Formally detained under Mental Health Act Section 46

15 - Formally detained under Mental Health Act Section 47 with section 49 restrictions

16 - Formally detained under Mental Health Act Section 47

17 - Formally detained under Mental Health Act Section 48 with section 49 restrictions

18 - Formally detained under Mental Health Act Section 48

19 - Formally detained under Mental Health Act Section 135

20 - Formally detained under Mental Health Act Section 136

31 - Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991

32 - Formally detained under other acts

35 - Subject to guardianship under Mental Health Act Section 7

36 - Subject to guardianship under Mental Health Act Section 37

37 - Formally detained under Mental Health Act Section 45A (Limited direction in force)

38 - Formally detained under Mental Health Act Section 45A (Limitation direction ended)

98 - Not Applicable

99 - Not Known

MENTAL HEALTH ACT 2007 MENTAL CATEGORY The primary reason for the detention of PATIENTS. R A - Mental disorder (Learning Disability not present or not primary reason for using Act)

B - Mental disorder (Learning Disability primary reason for using Act)

8 - Not applicable (i.e. not detained)

9 - Not Known (Not Recorded)


Mental Health Responsible Clinician Assignment Period

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) The start date of an assignment of a Mental Health Responsible Clinician to a patient. M
END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) The end date of an assignment of a Mental Health Responsible Clinician to a patient. R


Conditional Discharge

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) The start date of the Mental Health Conditional Discharge Period. M
END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) The end date of the Mental Health Conditional Discharge Period. R
MENTAL HEALTH CONDITIONAL DISCHARGE END REASON The reason a Mental Health Conditional Discharge Period ended. R 01 - Mental Health absolute discharge

02 - Recall of PATIENT

03 - Death of PATIENT

MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY The body or PERSON responsible for granting Mental Health Absolute Discharge. R 01 - Mental Health Tribunal

02 - Secretary of State


Community Treatment Order Recall

Name Description Conformance Codes & Primary Value Set
START DATE (COMMUNITY TREATMENT ORDER RECALL) The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). M
EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL) The date which the Community Treatment Order for a patient was due to expire. This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended R
END DATE (COMMUNITY TREATMENT ORDER RECALL) The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). R
COMMUNITY TREATMENT ORDER END REASON The reason for the termination of a period of a Community Treatment Order. R 01 - Patient discharged

02 - Community Treatment Order revoked

03 - Patient died

04 - Patient transferred outside England

05 - Patient transferred to another Health Care Provider


Community Treatment Order Recall

Name Description Conformance Codes & Primary Value Set
START TIME (COMMUNITY TREATMENT ORDER RECALL) The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). M
END TIME (COMMUNITY TREATMENT ORDER RECALL) The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). R


Hospital Provider Spell

Name Description Conformance Codes & Primary Value Set
HOSPITAL PROVIDER SPELL IDENTIFIER A unique identifier for each Hospital Provider Spell for a Health Care Provider. M
DECIDED TO ADMIT DATE The date a DECISION TO ADMIT was made. R
DECIDED TO ADMIT TIME The time a DECISION TO ADMIT was made. R
START DATE (HOSPITAL PROVIDER SPELL) The start date of a Hospital Provider Spell. M
START TIME (HOSPITAL PROVIDER SPELL) The start time of a Hospital Provider Spell. R
ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) The source of admission to a Hospital Provider Spell. R 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments)

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

49 - NHS other Hospital Provider - high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

87 - Independent Sector Healthcare Provider run hospital

88 - Hospice

98 - Not applicable

99 - Not Known

METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL) The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission. R 11 - Elective Admission: Waiting list

12 - Elective Admission: Booked

13 - Elective Admission: Planned

21 - Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE

22 - Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy

23 - Emergency Admission: Bed bureau

24 - Emergency Admission: Consultant Clinic, of this or another Health Care Provider

25 - Emergency Admission: Admission via Mental Health Crisis Resolution Team

2A - Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted

2B - Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency

2D - Emergency Admission: Other emergency admission

81 - Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency

98 - Not applicable

99 - Not Known

POSTCODE OF MAIN VISITOR The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell. R
ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) The estimated discharge date from a Hospital Provider Spell. R
PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) The planned discharge date from a Hospital Provider Spell. R
PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) The planned destination of a PATIENT on completion of a Hospital Provider Spell. R 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)

30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

48 - High Security Psychiatric Hospital, Scotland

49 - NHS other Hospital Provider - high security psychiatric accommodation

50 - NHS other Hospital Provider - medium secure unit

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

79 - PATIENT died or stillbirth

84 - Independent Sector Healthcare Provider run hospital - medium secure unit

87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit

88 - Hospice

89 - ORGANISATION responsible for forced repatriation

98 - Not applicable

99 - Not known

DISCHARGE DATE (HOSPITAL PROVIDER SPELL) The discharge date from a Hospital Provider Spell. R
DISCHARGE TIME (HOSPITAL PROVIDER SPELL) The discharge time from a Hospital Provider Spell. R
METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) The method of discharge from a Hospital Provider Spell. R 1 - Patient discharged on clinical advice or with clinical consent

3 - Patient discharged by mental health review tribunal, Home Secretary or court

4 - Patient died

6 - Patient discharged him/herself

7 - Patient discharged by a relative or advocate

8 - Not applicable (Hospital Provider Spell not finished at episode end (i.e. not discharged) or current episode unfinished)

9 - Method of Discharge not known

DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died. R 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)

30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

48 - High Security Psychiatric Hospital, Scotland

49 - NHS other Hospital Provider - high security psychiatric accommodation

50 - NHS other Hospital Provider - medium secure unit

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

79 - PATIENT died or stillbirth

84 - Independent Sector Healthcare Provider run hospital - medium secure unit

87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit

88 - Hospice

89 - ORGANISATION responsible for forced repatriation

98 - Not applicable

99 - Not known

POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell. R
TRANSFORMING CARE INDICATOR Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care R Y - Yes - Patient is in scope of transforming care

N - No - Patient is not in scope of transforming care

TRANSFORMING CARE CATEGORY Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care R 1 - Patient with autism (and no learning disability)

2 - Patient with a learning disability (and no autism)

3 - Patient with autism and a learning disability


Ward Stay

Name Description Conformance Codes & Primary Value Set
WARD STAY IDENTIFIER A unique identifier allocated for each Ward Stay during the hospital provider spell. M
START DATE (WARD STAY) The start date of a ward stay. M
START TIME (WARD STAY) The start time of a ward stay. R
END DATE (MENTAL HEALTH TRIAL LEAVE) The End Date of a period of Mental Health Trial Leave for a PATIENT. R
END DATE (WARD STAY) The end date of a ward stay. R
END TIME (WARD STAY) The end time of a ward stay. R
WARD SETTING TYPE (MENTAL HEALTH) The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell. R 01 - Child and Adolescent Mental Health Ward

02 - Paediatric Ward

03 - Adult Mental Health Ward

04 - Non Mental Health Ward

05 - Learning Disabilities Ward

06 - Older People's Mental Health Ward

INTENDED AGE GROUP (MENTAL HEALTH) The age group of PATIENTS intended to use a WARD indicated in the operational plan. R 10 - Child only

11 - Adolescent only

12 - Child and Adolescent

13 - Adult only

14 - Older Adult only

15 - Adult and Older Adult

99 - Any age

SEX OF PATIENTS CODE (MENTAL HEALTH) The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed. R 1 - Male

2 - Female

8 - Not specified

INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) The intended level of resources and intensity of care for the ward in which the person is placed. R 51 - Mental Illness intensive care: specially designated ward for Patients needing containment and more intensive management (e.g. Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where Patients may require one to one nursing while on a standard ward

52 - Mental Illness short stay: Patients intended to stay less than a year

53 - Mental Illness long stay: Patients intended to stay a year or more

61 - Learning Disability Patients in a designated or interim secure unit

62 - Learning Disability Patients intending to stay less than a year

63 - Learning Disability Patients intending to stay a year or more

WARD SECURITY LEVEL The level of security for a ward. R 0 - General (non-secure)

1 - Low Secure

2 - Medium Secure

3 - High Secure

LOCKED WARD INDICATOR An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit. R Y - Yes - is a locked WARD

N - No - is not a locked WARD

MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION The classification of the admitted PATIENT during a Ward Stay. R 10 - Acute adult mental health care

11 - Acute older adult mental health care (organic and functional)

12 - Adult Psychiatric Intensive Care Unit (acute mental health care)

13 - Adult Eating Disorders

14 - Mother and baby

15 - Adult Learning Disabilities

17 - Adult High dependency rehabilitation

19 - Adult Low secure

20 - Adult Medium secure

21 - Adult High secure

22 - Adult Neuro-psychiatry / Acquired Brain Injury

23 - General child and young PERSON admitted PATIENT - Child (including High Dependency)

24 - General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency)

25 - Eating Disorders admitted patient - Young person (13 years and over)

26 - Eating Disorders admitted patient - Child (12 years and under)

27 - Child and Young Person Low Secure Mental Illness

28 - Child and Young Person Medium Secure Mental Illness

29 - Child Mental Health admitted patient services for the Deaf

30 - Child and Young Person Learning Disabilities / Autism admitted patient

31 - Child and Young Person Low Secure Learning Disabilities

32 - Child and Young Person Medium Secure Learning Disabilities

33 - Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person

34 - Child and Young Person Psychiatric Intensive Care Unit

35 - Adult admitted patient continuing care

36 - Adult community rehabilitation unit

37 - Adult highly specialist high dependency rehabilitation unit

38 - Adult longer term high dependency rehabilitation unit

39 - Adult mental health admitted patient services for the Deaf

40 - Adult personality disorder

WARD CODE A unique identification of a WARD within a Health Care Provider. R


Assigned Care Professional

Name Description Conformance Codes & Primary Value Set
START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) The start date of an assignment of a Care Professional responsible for the care of the patient. M
END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) The end date of an assignment of a Care Professional responsible for the care of the patient. R
TREATMENT FUNCTION CODE (MENTAL HEALTH) 'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest. R 319 Respite Care Service

348 Post-COVID-19 Syndrome Service

656 Clinical Psychology Service

700 Learning Disability Service

710 Adult Mental Health Service

711 Child and Adolescent Psychiatry Service

712 Forensic Psychiatry Service

713 Medical Psychotherapy Service

715 Old Age Psychiatry Service

720 Eating Disorders Service

721 Addiction Service

722 Liaison Psychiatry Service

723 Psychiatric Intensive Care Service

724 Perinatal Mental Health Service

725 Mental Health Recovery and Rehabilitation Service

726 Mental Health Dual Diagnosis Service

727 Dementia Assessment Service

730 Neuropsychiatry Service


Mental Health Delayed Discharge

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place. M
END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) The date that a period of delayed discharge for a patient who had previously been ready for discharge ended. This may end because the patient was discharged or because the patient was no longer ready for discharge. R
MENTAL HEALTH DELAYED DISCHARGE REASON The reason that a patient was not able to be discharged despite being medically ready for discharge. R A2 - Awaiting care coordinator allocation

B1 - Awaiting public funding

C1 - Awaiting further non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)

D1 - Awaiting Care Home Without Nursing placement or availability

D2 - Awaiting Care Home With Nursing placement or availability

E1 - Awaiting care package in own home

F2 - Awaiting community equipment, telecare and/or adaptations

G2 - Patient or Family choice (reason not stated by patient or family)

G3 - Patient or Family choice - Non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)

G4 - Patient or Family choice - Care Home Without Nursing placement

G5 - Patient or Family choice - Care Home With Nursing placement

G6 - Patient or Family choice - Care package in own home

G7 - Patient or Family choice - Community equipment, telecare and/or adaptations

G8 - Patient or Family Choice - general needs housing/private landlord acceptance as patient NOT covered by Housing Act/Care Act

G9 - Patient or Family choice - Supported accommodation

G10 - Patient or Family choice - Emergency accommodation from the Local Authority under the Housing Act

G11 - Patient or Family choice - Child or young person awaiting social care or family placement

G12 - Patient or Family choice - Ministry of Justice agreement/permission of proposed placement

H1 - Disputes

I2 - Housing - Awaiting availability of general needs housing/private landlord accommodation acceptance as patient NOT covered by Housing Act and/or Care Act

I3 - Housing - Single homeless patients or asylum seekers NOT covered by Care Act

J2 - Housing - Awaiting supported accommodation

K2 - Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act

L1 - Child or young person awaiting social care or family placement

M1 - Awaiting Ministry of Justice agreement/permission of proposed placement

N1 - Awaiting outcome of legal requirements (mental capacity/mental health legislation)

P1 - Awaiting residential special school or college placement or availability

Q1 - Lack of local education support

R1 - Public safety concern unrelated to clinical treatment need (care team)

R2 - Public safety concern unrelated to clinical treatment need (Ministry of Justice)

S1 - No lawful community care package available

T1 - Lack of health care service provision

T2 - Lack of social care support

98 - No reason given

MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable. R 04 - NHS, excluding housing

05 - Social Care, excluding housing

06 - Both (NHS and Social Care), excluding housing

07 - Housing (including supported/specialist housing)

ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE) The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period. R


Restrictive Intervention Incident

Name Description Conformance Codes & Primary Value Set
RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell M
START DATE (RESTRICTIVE INTERVENTION INCIDENT) The Start Date of the Restrictive Intervention Incident as reported by the Care Professional. M
START TIME (RESTRICTIVE INTERVENTION INCIDENT) The Start Time of the Restrictive Intervention Incident as reported by the Care Professional. R
END DATE (RESTRICTIVE INTERVENTION INCIDENT) The End Date of the Restrictive Intervention Incident as reported by the Care Professional. R
END TIME (RESTRICTIVE INTERVENTION INCIDENT) The End Time of the Restrictive Intervention Incident as reported by the Care Professional. R
RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT) An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention. R Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention

RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT) The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention. R 1 - Clinical decision to delay

2 - Patient refused to take part

3 - Other (not listed)

RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL) An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention. R Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention

RESTRICTIVE INTERVENTION REASON The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell. R 10 - Prevent a patient being violent to others

11 - Prevent a patient causing serious intentional harm to themselves

12 - Prevent a patient causing serious physical injury to themselves by accident

13 - Lawfully administer medicines or other medical treatment

14 - Facilitate personal care

15 - Facilitate nasogastric (NG) feeding

16 - Prevent the patient exhibiting extreme and prolonged over-activity

17 - Prevent the PATIENT exhibiting otherwise dangerous behaviour

18 - Undertake a search of the patient’s clothing or property to ensure the safety of others

19 - Prevent the patient absconding from lawful custody

98 - Other (not listed)

99 - Not Known (Not Recorded)


Restrictive Intervention Type

Name Description Conformance Codes & Primary Value Set
RESTRICTIVE INTERVENTION TYPE IDENTIFIER A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell M
START DATE (RESTRICTIVE INTERVENTION TYPE) The Start Date of the Restrictive Intervention Type as reported by the Care Professional. M
START TIME (RESTRICTIVE INTERVENTION TYPE) The Start Time of the Restrictive Intervention Type as reported by the Care Professional. R
RESTRICTIVE INTERVENTION TYPE Type of RESTRICTIVE INTERVENTION used. R 01 - Physical restraint - Prone

07 - Physical restraint - Standing

08 - Physical restraint - Restrictive escort

09 - Physical restraint - Supine

10 - Physical restraint - Side

11 - Physical restraint - Seated

12 - Physical restraint - Kneeling

13 - Physical restraint - Other (not listed)

14 - Chemical restraint - Injection (Rapid Tranquillisation)

15 - Chemical restraint - Injection (Non Rapid Tranquillisation)

16 - Chemical restraint - Oral

17 - Chemical restraint - Other (not listed)

04 - Mechanical restraint

05 - Seclusion

06 - Segregation

END DATE (RESTRICTIVE INTERVENTION TYPE) The End Date of the Restrictive Intervention Type as reported by the Care Professional. R
END TIME (RESTRICTIVE INTERVENTION TYPE) The End Time of the Restrictive Intervention Type as reported by the Care Professional. R
RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT) An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention. R Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention

RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL) An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention. R Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention

RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON) An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention. R Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention


Police Assistance Request

Name Description Conformance Codes & Primary Value Set
POLICE ASSISTANCE REQUEST DATE The date the call was made to request police assistance M
POLICE ASSISTANCE REQUEST TIME The time the call was made to request police assistance R
POLICE ASSISTANCE ARRIVAL DATE The date the Police arrived following the request for assistance R
POLICE ASSISTANCE ARRIVAL TIME The time the Police arrived following the request for assistance R
POLICE RESTRAINT OR FORCE USED INDICATOR An indication of whether the police used restraint or force on a PATIENT. R Y - Yes - the police used restraint or force on a PATIENT

N - No - the police did not use restraint or force on a PATIENT


Assault

Name Description Conformance Codes & Primary Value Set
DATE OF ASSAULT ON PATIENT The DATE that an instance of assault on the PATIENT by another PATIENT occurred. M


Self-Harm

Name Description Conformance Codes & Primary Value Set
DATE OF SELF-HARM The date that an incident of self-harm for the patient occurred. M
OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE) The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL. M


Home Leave

Name Description Conformance Codes & Primary Value Set
START DATE (HOME LEAVE) The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. M
START TIME (HOME LEAVE) The start time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. R
END DATE (HOME LEAVE) The end date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. R
END TIME (HOME LEAVE) The end time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. R


Leave Of Absence

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH LEAVE OF ABSENCE) The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. M
START TIME (MENTAL HEALTH LEAVE OF ABSENCE) The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. R
END DATE (MENTAL HEALTH LEAVE OF ABSENCE) The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. R
END TIME (MENTAL HEALTH LEAVE OF ABSENCE) The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. R
MENTAL HEALTH LEAVE OF ABSENCE END REASON The reason a Mental Health Leave of Absence ended. R 01 - Patient returned on or before day specified

02 - Leave revoked and patient recalled by Mental Health Responsible Clinician

03 - Period of leave to be extended

04 - Patient failed to return on or before day specified and is absent without leave

05 - Patient's liability for detention terminated by Mental Health Responsible Clinician

06 - Patient's liability for detention terminated by Mental Health Act Review Tribunal

07 - Patient's liability for detention terminated by Hospital Managers

08 - Patient died

96 - Other (not listed)

99 - MENTAL HEALTH LEAVE OF ABSENCE END REASON Not Known (Not Recorded)

ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted. R Y - Yes - a period of Mental Health Leave of Absence is escorted

N - No - a period of Mental Health Leave of Absence is not escorted


Mental Health Trial Leave

Name Description Conformance Codes & Primary Value Set
START DATE (MENTAL HEALTH TRIAL LEAVE) The Start Date of a period of Mental Health Trial Leave for a PATIENT. M
START TIME (MENTAL HEALTH TRIAL LEAVE) The Start Time of a period of Mental Health Trial Leave for a PATIENT. R
END TIME (MENTAL HEALTH TRIAL LEAVE) The End Time of a period of Mental Health Trial Leave for a PATIENT. R


Hospital Provider Spell Commissioner Assignment Period

Name Description Conformance Codes & Primary Value Set
START DATE (COMMISSIONER ASSIGNMENT PERIOD) The Start Date of the Commissioner Assignment Period. M
END DATE (COMMISSIONER ASSIGNMENT PERIOD) The End Date of the Commissioner Assignment Period. R


Specialised Mental Health Exceptional Package of Care

Name Description Conformance Codes & Primary Value Set
SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE The amount charged for the SMH EPC in the reporting period M
START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) The start date of an SMH EPC. M
END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) The End Date of an SMH EPC. R


Medical History (Previous Diagnosis)

Name Description Conformance Codes & Primary Value Set
DIAGNOSIS SCHEME IN USE (MENTAL HEALTH) The code scheme basis of the Diagnosis. M 02 - ICD-10

06 - SNOMED CT®

PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) A unique identifier for a clinical diagnosis from a specific classification or clinical terminology. M
CODED DIAGNOSIS TIMESTAMP The date, time and time zone for the PATIENT DIAGNOSIS. R


Provisional Diagnosis

Name Description Conformance Codes & Primary Value Set
PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare. M


Primary Diagnosis

Name Description Conformance Codes & Primary Value Set
PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem. M


Secondary Diagnosis

Name Description Conformance Codes & Primary Value Set
SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded. M
CODED DIAGNOSIS TIMESTAMP The date, time and time zone for the PATIENT DIAGNOSIS. R


Coded Scored Assessment (Referral)

Name Description Conformance Codes & Primary Value Set
CODED ASSESSMENT TOOL TYPE (SNOMED CT) The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT. M
PERSON SCORE The observable value (score) resulting from an assessment. M
ASSESSMENT TOOL COMPLETION TIMESTAMP The date, time and time zone on which the assessment took place M


Care Programme Approach (CPA) Care Episode

Name Description Conformance Codes & Primary Value Set
CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER A unique identifier allocated to each Care Programme Approach Care Episode. M
START DATE (CARE PROGRAMME APPROACH CARE) The start date for Care Programme Approach Care for the patient. M
END DATE (CARE PROGRAMME APPROACH CARE) The end date for Care Programme Approach Care for the patient. R


Care Programme Approach (CPA) Review

Name Description Conformance Codes & Primary Value Set
CARE PROGRAMME APPROACH REVIEW DATE The date of the Care Programme Approach review. M


Clustering Tool Assessment

Name Description Conformance Codes & Primary Value Set
CLUSTERING TOOL ASSESSMENT IDENTIFIER A unique identifier for each clustering tool assessment that takes place for each patient. M
CLUSTERING TOOL ASSESSMENT CATEGORY The category of the clustering tool assessment completed. M 01 - Adult Mental Health Clustering Tool

03 - Learning Disabilities Clustering Tool

04 - Forensic Mental Health Clustering Tool

05 - Forensic Learning Disabilities Clustering Tool

06 - Child and Adolescent Mental Health Needs Based Grouping Tool

ASSESSMENT TOOL COMPLETION DATE The date on which a clustering tool assessment was completed for a patient. M
ASSESSMENT TOOL COMPLETION TIME The time on which a clustering tool assessment was completed for a patient. R
CLUSTERING TOOL ASSESSMENT REASON The reason that the clustering tool assessment for the patient was undertaken. R 10 - Initial assessment

11 - Scheduled re-assessment

12 - Re-assessment following significant unanticipated change in need

97 - Other Reason (not listed)

99 - CLUSTERING TOOL ASSESSMENT REASON Not Known (Not Recorded)

MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation. R A - Non-Psychotic

B - Psychotic

C - Organic

Z - Unable to assign patient to Mental Health Care Cluster Super Class

ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm. R 00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)

02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)

04 - Care Cluster 4 - Non-Psychotic (Severe)

05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.

10 - Care Cluster 10 - First Episode Psychosis

11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14 - Psychotic Crisis

15 - Care Cluster 15 - Severe Psychotic Depression

16 - Care Cluster 16 - Dual Diagnosis

17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18 - Cognitive Impairment (Low Need)

19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)

21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)

LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. P
FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. P


Care Cluster

Name Description Conformance Codes & Primary Value Set
START DATE (CARE CLUSTER ASSIGNMENT PERIOD) The date on which the assignment of a patient to a Care Cluster started. M
START TIME (CARE CLUSTER ASSIGNMENT PERIOD) The time on which the assignment of a patient to a Care Cluster started. R
ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm. R 00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)

02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)

04 - Care Cluster 4 - Non-Psychotic (Severe)

05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.

10 - Care Cluster 10 - First Episode Psychosis

11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14 - Psychotic Crisis

15 - Care Cluster 15 - Severe Psychotic Depression

16 - Care Cluster 16 - Dual Diagnosis

17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18 - Cognitive Impairment (Low Need)

19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)

21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)

CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL. R 10 - Getting Advice: Neurodevelopmental Assessment (NEU)

11 - Getting Advice: Signposting and Self-management Advice (ADV)

12 - Getting Help: Attention Deficit Hyperactivity Disorder (ADHD)

13 - Getting Help: Autism (AUT)

14 - Getting Help: Behavioural and/or Conduct Disorders (BEH)

15 - Getting Help: Bipolar Disorder (BIP)

16 - Getting Help: Depression (DEP)

17 - Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP)

18 - Getting Help: Obsessive compulsive disorder (OCD)

19 - Getting Help: Post-traumatic stress disorder (PTS)

20 - Getting Help: Self-harm (SHA)

21 - Getting Help: Social Anxiety Disorder (SOC)

22 - Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM)

23 - Getting Help: Co-occurring Emotional Difficulties (EMO)

24 - Getting Help: Difficulties Not Covered by Other Groupings (DNC)

25 - Getting More Help: Eating Disorders (EAT)

26 - Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP)

27 - Getting More Help: Psychosis (PSY)

28 - Getting More Help: Difficulties of Severe Impact (DSI)

LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. P
FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. R 00 - Care Cluster 0: Variance

01 - Care Cluster 1: Common Mental Health Problems (Low Severity)

02 - Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3: Non-Psychotic (Moderate Severity)

04 - Care Cluster 4: Non-Psychotic (Severe)

05 - Care Cluster 5: Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders

08b - Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders

10 - Care Cluster 10: First Episode Psychosis

11 - Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14: Psychotic Crisis

15 - Care Cluster 15: Severe Psychotic Depression

16 - Care Cluster 16: Dual Diagnosis

17 - Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18: Cognitive Impairment (Low Need)

19 - Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20: Cognitive Impairment or Dementia (High Need)

21 - Care Cluster 21: Cognitive Impairment or Dementia (High Physical or Engagement)

FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. P
END DATE (CARE CLUSTER ASSIGNMENT PERIOD) The date on which the assignment of a patient to a Care Cluster ended. R
END TIME (CARE CLUSTER ASSIGNMENT PERIOD) The time on which the assignment of a patient to a Care Cluster ended. R


Five Forensic Pathways

Name Description Conformance Codes & Primary Value Set
FIVE FORENSIC PATHWAYS ASSESSMENT DATE The date on which a Five Forensic Pathways assessment was completed for a patient. M
FIVE FORENSIC PATHWAYS ASSESSMENT REASON The reason for which a Five Forensic Pathways assessment was undertaken. R 10 - Initial Assessment

11 - Scheduled Re-Assessment

12 - Re-Assessment following significant unanticipated change in need

97 - Other Reason (not listed)

99 - Not Known (Not Recorded)

FIVE FORENSIC PATHWAYS CODE The Five Forensic Pathway assigned to a patient. M 0 - Unable to assign patient to one of the five forensic pathways

1 - Treatment responsive group

2 - Treatment resistant group – challenging behaviour

3 - Treatment resistant group – continuing care

4 - Personality disorder group – prison transfer

5 - Personality disorder group – co-morbidity


Care Professionals

Name Description Conformance Codes & Primary Value Set
PROFESSIONAL REGISTRATION BODY CODE A code which identifies the PROFESSIONAL REGISTRATION BODY. R 01 - General Chiropractic Council

02 - General Dental Council

03 - General Medical Council

04 - General Optical Council

05 - Social Care Wales

08 - Health and Care Professions Council

09 - Nursing and Midwifery Council

16 - General Pharmaceutical Council

17 - General Osteopathic Council

18 - Social Work England

PROFESSIONAL REGISTRATION ENTRY IDENTIFIER The registration identifier allocated by an ORGANISATION. R
CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) The staff group of a CARE PROFESSIONAL working in a Mental Health Service. R 01 - Medical

02 - Nursing

03 - Psychology

04 - Primary Mental Health

05 - Child and Adolescent Psychotherapy

06 - Counselling

07 - Family and Systemic Psychotherapy

08 - Occupational Therapy

09 - Social Work

10 - Creative Therapy

11 - Other Therapy (Qualified)

12 - Education

13 - Speech and Language Therapy

97 - Other (Qualified)

98 - Other (Unqualified)

MAIN SPECIALTY CODE (MENTAL HEALTH) The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period. R 600 - General Medical Practice

700 - Learning Disability

710 - Adult Mental illness

711 - Child and Adolescent Psychiatry

712 - Forensic Psychiatry

713 - Medical Psychotherapy

715 - Old age psychiatry

950 - Nursing

960 - Allied Health Professional

OCCUPATION CODE An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual. R
CARE PROFESSIONAL (JOB ROLE CODE) A National Code for a POSITION applicable to an EMPLOYEE. R


IAPT


Data Linkage

Name Description Conformance Codes & Primary Value Set
CARE PERSONNEL LOCAL IDENTIFIER A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system. M

Header

Name Description Conformance Codes & Primary Value Set
DATA SET VERSION NUMBER The version of the data set that this submission file is for. M
ORGANISATION IDENTIFIER (CODE OF PROVIDER) This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database M
ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation. M
PRIMARY DATA COLLECTION SYSTEM IN USE The name of the Primary Data Collection System in use by the Health Care Provider. M
REPORTING PERIOD START DATE The reporting period start date to which this file refers M
REPORTING PERIOD END DATE The reporting period end date to which this file refers M
DATE AND TIME DATE SET CREATED Date/time this upload file was created M

MPI

Name Description Conformance Codes & Primary Value Set
EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The type of Educational Establishment that the student is attending. R 1 - School

2 - College

3 - University

4 - Other Educational Establishment not listed

8 - Not applicable (Patient is not a student)

Z - Not stated (Patient asked but declined to provide a response)

X - Not Known (Not Recorded)

Employment Status

Name Description Conformance Codes & Primary Value Set
SELF EMPLOYED INDICATOR 'An indication of whether an employed person is self-employed. R Y - Yes - Employed as a self-employed worker

N - No - Not self employed

8 - Not Applicable (Person is unemployed)

Z - Not stated (Person asked but declined to provide a response)

SICKNESS ABSENCE INDICATOR 'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness. R Y - Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness

N - No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness

8 - Not Applicable (The person is unemployed)

Z - Not stated (Person asked but declined to provide a response)

X - Not Known (Not Recorded)

STATUTORY SICK PAY RECEIPT INDICATOR 'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON. R Y - Yes - the person is currently in receipt of Statutory Sick Pay

N - No - the person is currently not in receipt of Statutory Sick Pay

U - Unknown (Person asked and does not know or is not sure)

Z - Not stated (Person asked but declined to provide a response)

BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 'An indication of whether a patient is currently receiving benefits, as stated by the patient. R Y - Yes - the PATIENT is currently in receipt of a benefit

N - No - the PATIENT is not currently in receipt of a benefit

U - Unknown (Person asked and does not know or is not sure)

Z - Not stated (Person asked but declined to provide a response)

EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR 'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient. R Y - Yes - receiving Employment and Support Allowance

N - No - not receiving Employment and Support Allowance

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)

UNIVERSAL CREDIT RECEIPT INDICATOR 'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient. R Y - Yes - receiving Universal Credit

N - No - not receiving Universal Credit

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)

PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR 'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient. R Y - Yes - receiving Personal Independence Payment

N - No - Not receiving Personal Independence Payment

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)

EMPLOYMENT SUPPORT SUITABILITY INDICATOR 'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support. R Y - Yes - the patient is a suitable candidate for referral to Employment Support

N - No - the patient is not a suitable candidate for referral to Employment Support

N/A - Not Applicable

EMPLOYMENT SUPPORT REFERRAL DATE The date the PATIENT was referred for Employment Support. R


Social & Personal Circumstances

Name Description Conformance Codes & Primary Value Set
SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE R


Referral

Name Description Conformance Codes & Primary Value Set
SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES The source of referral to a Mental Health Service. R A1 - Primary Health Care: General Medical Practitioner Practice

A2 - Primary Health Care: Health Visitor

A3 - Other Primary Health Care

A4 - Primary Health Care: Maternity Service

B1 - Self Referral: Self

B2 - Self Referral: Carer/Relative

C1 - Local Authority and Other Public Services: Social Services

C2 - Local Authority and Other Public Services: Education Service / Educational Establishment

C3 - Local Authority and Other Public Services: Housing Service

D1 - Employer

D2 - Employer: Occupational Health

E1 - Justice System: Police

E2 - Justice System: Courts

E3 - Justice System: Probation Service

E4 - Justice System: Prison

E5 - Justice System: Court Liaison and Diversion Service

E6 - Justice System: Youth Offending Team

F1 - Child Health: School Nurse

F2 - Child Health: Hospital-based Paediatrics

F3 - Child Health: Community-based Paediatrics

G1 - Independent sector - Medium Secure Inpatients

G2 - Independent Sector - Low Secure Inpatients

G3 - Other Independent Sector Mental Health Services

G4 - Voluntary Sector

H1 - Acute Secondary Care: Emergency Care Department

H2 - Other secondary care specialty

I1 - Temporary transfer from another Mental Health NHS Trust

I2 - Permanent transfer from another Mental Health NHS Trust

M1 - Other: Asylum Services

M2 - Other: Telephone or Electronic Access Service

M3 - Other: Out of Area Agency

M4 - Other: Drug Action Team / Drug Misuse Agency

M5 - Other: Jobcentre Plus

M6 - Other SERVICE or agency

M7 - Other: Single Point of Access Service

M8 - Debt agency

N1 - Stepped up from low intensity Improving Access to Psychological Therapies Service

N2 - Stepped down from high intensity Improving Access to Psychological Therapies Service

N4 - Other Improving Access to Psychological Therapies Service

P1 - Internal Referral

Q1 - Mental Health Drop In Service

YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT. R
PREVIOUS DIAGNOSED CONDITION INDICATOR An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT. R Y - Yes - this is a recurrence of a previously diagnosed condition

N - No - this is not a recurrence of a previously diagnosed condition

U - Unknown (Patient asked and does not know or is unsure)

Z - Not stated (Patient asked but declined to provide a response)

DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service. R Referred but not seen

50 - Not assessed


Seen but not taken on for a course of treatment

10 - Not suitable for IAPT service - no action taken or directed back to referrer

11 - Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient

12 - Discharged by mutual agreement following advice and support

13 - Referred to another therapy service by mutual agreement

14 - Suitable for IAPT service, but patient declined treatment that was offered

16 - Incomplete Assessment (Patient dropped out)

17 - Deceased (Seen but not taken on for a course of treatment)

95 - Not Known (Seen but not taken on for a course of treatment)


Seen and taken on for a course of treatment

46 - Mutually agreed completion of treatment

47 - Termination of treatment earlier than Care Professional planned

48 - Termination of treatment earlier than patient requested

49 - Deceased (Seen and taken on for a course of treatment)

96 - Not Known (Seen and taken on for a course of treatment)

SERVICE DISCHARGE DATE The date a PATIENT was discharged from a SERVICE. R

Onward Referral

Name Description Conformance Codes & Primary Value Set
ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The reason why the patient was referred from one service to another service, which may be in the same or a different organisation. R 1 - Transfer of Clinical Responsibility

2 - For Opinion Only

3 - For Diagnostic Test Only

4 - New Referral (Non Transfer)

5 - Stepped up from low intensity Improving Access to Psychological Therapies Service

6 - Stepped down from high intensity Improving Access to Psychological Therapies Service

96 - Other (not listed)

98 - Onward Referral Reason Not Applicable

99 - Not Known (Not Recorded)

Waiting Time Pauses

Name Description Conformance Codes & Primary Value Set
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION. M
ACTIVITY SUSPENSION START DATE The date on which the break from the ACTIVITY starts. M
ACTIVITY SUSPENSION END DATE The date on which the break from the ACTIVITY ends. R
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set. Patient Initiated pause in the waiting period. R 1 - Patient unavailable due to holiday

2 - Patient unavailable due to other health needs

3 - Patient stated not available - other reason (not listed)

Care Contact

Name Description Conformance Codes & Primary Value Set
APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice. R Y - Yes - Appointment slot could be reallocated

N - No - Appointment slot could not be reallocated

INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service. M Y - Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological

Therapies Long Term Condition Service

N - No - the Improving Access to Psychological Therapies Contact was not provided by an Integrated Improving Access to Psychological

Therapies Long Term Condition Service

APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The type of Improving Access to Psychological Therapies APPOINTMENT. M 1 - Assessment

2 - Treatment

3 - Assessment and treatment

4 - Review only

5 - Review and treatment

6 - Follow-up appointment after treatment end

10 - Employment Support

98 - Other (not listed)

99 - Not Known (Not Recorded)

INTERNET ENABLED THERAPY PROGRAMME The name of the Internet Enabled Therapy Programme delivered to a PATIENT. R
NUMBER OF GROUP THERAPY PARTICIPANTS The number of persons who participated in the Group Therapy, excluding the Care Professionals. R
NUMBER OF GROUP THERAPY FACILITATORS The number of Care Professionals who facilitated the Group Therapy. R
PSYCHOTROPIC MEDICATION USAGE INDICATION CODE An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT. R 1 - Prescribed but not taking

2 - Prescribed and taking

3 - Not Prescribed

UU - Unknown (Patient asked and does not know or is not sure)

ZZ - Not stated (Patient asked but declined to provide a response)

LANGUAGE CODE (TREATMENT) The language used for the delivery of treatment to the Patient. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions. R All Spoken Languages

- ISO 639-1 codes at http://www.loc.gov/standards/iso639-2/php/code_list.php


Extensions

q1 - Braille (for people who are unable to see)

q2 - American Sign Language

q3 - Australian Sign Language

q4 - British Sign Language

q5 - Makaton (devised for children and adults with a variety of communication and Learning Disabilities)

INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter. R 1 - Yes - Professional interpreter

2 - Yes - Family member or friend

3 - Yes - Another Person

4 - No - Interpreter not required

5 - No - Interpreter was required but did not attend

X - Not Known (Not Recorded)

Internet Therapy Log

Name Description Conformance Codes & Primary Value Set
START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. M
END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. M
INTERNET ENABLED THERAPY PROGRAMME The name of the Internet Enabled Therapy Programme delivered to a PATIENT. M
DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period. M
INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy. R Y - Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy

N - No - an Internet Enabled Therapy Integrated Software Engine was not used as part of Internet Enabled Therapy

Medical History Previous Diagnosis

Name Description Conformance Codes & Primary Value Set
DIAGNOSIS DATE DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS. R

Long Term Condition

Name Description Conformance Codes & Primary Value Set
LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY) The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition. M

Presenting Complaints

Name Description Conformance Codes & Primary Value Set
PRESENTING COMPLAINT (CODED CLINICAL ENTRY) The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL M
PRESENTING COMPLAINT CODING SIGNIFICANCE The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL. R 1 - Primary Presenting Complaint

2 - Secondary Presenting Complaint

PRESENTING COMPLAINT RECORDED DATE The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded. R

Care Cluster

Name Description Conformance Codes & Primary Value Set
END TIME (CARE CLUSTER ASSIGNMENT PERIOD) The time on which the assignment of a patient to a Care Cluster ended. R

Care Personnel Qualification

Name Description Conformance Codes & Primary Value Set
CARE PERSONNEL LOCAL IDENTIFIER A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. M
QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The qualification or individual accreditation attained or planned to be attained, by the Care Personnel. M 10 - Curriculum for Psychological Wellbeing Practitioners (PWP)

11 - Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT)

12 - Curriculum for Counselling for Depression (CfD)

13 - Curriculum for Couple Therapy for Depression

(CTfD) / Curriculum for Behavioural Couples

Therapy (BCT) for Depression

14 - Curriculum for Dynamic

Interpersonal Therapy (DIT) for Depression

15 - Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT)

16 - Curriculum for Mindfulness-based Cognitive Therapy (MBCT)

17 - Curriculum for Eye Movement Desensitisation Reprocessing (EMDR)

30 - Curriculum for Employment Advisers

31 - Curriculum for Senior Employment Advisers

EMPLOYEE QUALIFICATION AWARDED DATE The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course. R
EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying. R


Freeform Placeholder

Name Description Conformance Codes & Primary Value Set
FREEFORM NOTES Any related notes deemed useful for inclusion within the DDS R
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