Mental Health FHIR Store Mappings: Difference between revisions

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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.
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.<ol>
You can find the expanded data specification for the MHSDS outlined below.
 
== Patient Demographics ==
<br /><ol>
       <!-- subsection items -->    </ol>   
       <!-- subsection items -->    </ol>   
   
   
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!Description
!Description
!Conformance
!Conformance
! FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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|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.
|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
|M
|Patient.Identifier
|
|
|-
|-
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|The ORGANISATION IDENTIFIER of the organisation that assigned the local patient identifier.
|The ORGANISATION IDENTIFIER of the organisation that assigned the local patient identifier.
|M
|M
|Patient.Organization.identifier
|
|
|-
|-
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| ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) is the ORGANISATION IDENTIFIER of the Educational Establishment, including Schools.
| ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) is the ORGANISATION IDENTIFIER of the Educational Establishment, including Schools.
|R
|R
| Patient.Organization.identifier
|
|
|-
|-
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|A number used to identify a PATIENT uniquely within the NHS in England and Wales
|A number used to identify a PATIENT uniquely within the NHS in England and Wales
|R
|R
|Patient.identifier(nhsnumber)
|
|
|-
|-
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|The NHS NUMBER STATUS INDICATOR of the PATIENT
|The NHS NUMBER STATUS INDICATOR of the PATIENT
|R
|R
|CareConnect-NHSNumberVerificationStatus-1<br /><nowiki>https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-NHSNumberVerificationStatus-1</nowiki>
|01- Number present and verified
|01- Number present and verified


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|The date on which a PERSON was born or is officially deemed to have been born
|The date on which a PERSON was born or is officially deemed to have been born
|R
|R
|Patient.birthDate
|
|
|-
|-
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|The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence'
|The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence'
|R
|R
|Patient.address.postalCode
|
|
|-
|-
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|The gender identity of a PERSON as stated by the PERSON
|The gender identity of a PERSON as stated by the PERSON
|R
|R
|Patient.gender.code
|1- Male (including trans man)
|1- Male (including trans man)


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| An indication of whether the patient's gender identity is the same as their gender assigned at birth.
| An indication of whether the patient's gender identity is the same as their gender assigned at birth.
|R
|R
|Patient.gender.extension(suggestion of an extension for '''GENDER IDENTITY SAME AT BIRTH INDICATOR''')
|Y- Yes - the person's gender identity is the same as their gender assigned at birth  
|Y- Yes - the person's gender identity is the same as their gender assigned at birth  


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|The gender of a PERSON.<br />PERSON STATED GENDER CODE is self declared or inferred by observation for those unable to declare their PERSON STATED GENDER.
|The gender of a PERSON.<br />PERSON STATED GENDER CODE is self declared or inferred by observation for those unable to declare their PERSON STATED GENDER.
|R
|R
|Patient.gender.code
| 1- Male  
| 1- Male  


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|The legal marital status of a PERSON.
|The legal marital status of a PERSON.
| R
| R
|Patient.maritalStatus
| S- Single
| S- Single


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|The ethnicity of a PERSON, as specified by the PERSON.
|The ethnicity of a PERSON, as specified by the PERSON.
|R
|R
|Patient.extension(ethnicCategory)
|A- White - British
|A- White - British


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|Placeholder data item to accommodate the 2021 census when it goes live
|Placeholder data item to accommodate the 2021 census when it goes live
|P
|P
|Patient.extension(suggestion of an extension for ETHNIC CATEGORY 2021)
|
|
|-
|-
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|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.
|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
|R
| Patient.communication.language
| All Spoken Languages
| All Spoken Languages


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|The date on which a person died or is officially deemed to have died, as recorded on the death certificate.
|The date on which a person died or is officially deemed to have died, as recorded on the death certificate.
|R
|R
|Patient.deceased[x].deceasedDateTime
|
|
|}<br />
|}<br />
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!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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|The ORGANISATION CODE of the GP Practice that the PATIENT is registered with.
|The ORGANISATION CODE of the GP Practice that the PATIENT is registered with.
|M
|M
| Patient.generalPractitioner
|
|
|-
|-
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|Start Date on which the PERSON registered with a General Medical Practitioner Practice.
|Start Date on which the PERSON registered with a General Medical Practitioner Practice.
|R
|R
|Patient.generalPractitioner.extension(suggestion of an extension for START DATE (GMP PATIENT REGISTRATION))
|
|
|-
|-
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|The DATE on which the PERSON ceased to be registered with a General Medical Practitioner Practice.
|The DATE on which the PERSON ceased to be registered with a General Medical Practitioner Practice.
|R
|R
|Patient.generalPractitioner.extension(suggestion of an extension for END DATE (GMP PATIENT REGISTRATION))
|
|
|}<br />
|}<br />
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!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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|An indication of the type of accommodation that a PATIENT currently has. This should be based on the PATIENT's main or permanent residence.
|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
|M
|Patient.address.extension(suggestion of an extension for Accommodation Type)
|01- Owner occupier
|01- Owner occupier


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|An indication of whether the main/permanent residence of the patient is settled accommodation.
|An indication of whether the main/permanent residence of the patient is settled accommodation.
|R
|R
|Patient.address.extension(suggestion of an extension for Settled Accommodation Indicator)
|Y- Yes - Settled Accommodation
|Y- Yes - Settled Accommodation


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


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|The date that the patient's accommodation type started.
|The date that the patient's accommodation type started.
|R
|R
|Patient.address.extension(suggestion of an extension for ACCOMMODATION TYPE START DATE)
|
|
|-
|-
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|The date that the patient's accommodation type ended.
|The date that the patient's accommodation type ended.
|R
|R
|Patient.address.extension(suggestion of an extension for ACCOMMODATION TYPE START END)
|
|
|}<br />
|}<br />
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!Description
!Description
! Conformance
! Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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| The current PRIMARY EMPLOYMENT status of a PERSON.
| The current PRIMARY EMPLOYMENT status of a PERSON.
|M
|M
|Patient.extension(suggestion of an extension for EMPLOYMENT STATUS)
|01- Employed  
|01- Employed  


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|The date that the patient's employment status started.
|The date that the patient's employment status started.
|R
|R
|Patient.extension(suggestion of an extension for EMPLOYMENT STATUS START DATE)
|
|
|-
|-
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|The date that the patient's employment status ended.
|The date that the patient's employment status ended.
|R
|R
|Patient.extension(suggestion of an extension for EMPLOYMENT STATUS END DATE)
|
|
|-
|-
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| The date that the patient's employment status details were recorded by the healthcare professional.
| The date that the patient's employment status details were recorded by the healthcare professional.
|R
|R
|Patient.extension(suggestion of an extension for EMPLOYMENT STATUS RECORD DATE)
|
|
|-
|-
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|The number of hours worked in a typical week.
|The number of hours worked in a typical week.
|R
|R
|Patient.extension(suggestion of an extension for WEEKLY HOURS WORKED)
|01- 30+ hours
|01- 30+ hours


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!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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|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
|Patient.extension(disability)
|Yes - PATIENT requires constant care and/or supervision
|
 
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
|Patient.link.other(RelatedPerson)
|Yes - PATIENT has parental responsibilities for a child or young person
|
 
No - PATIENT does not have parental responsibilities for a child or young person
 
Not Stated (PATIENT asked but declined to provide a response)
 
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
|Patient.extension(suggestion of an extension for YOUNG CARER INDICATOR)
|Yes - PATIENT has a caring role for an ill or disabled parent, Carer or sibling
|
 
No - PATIENT does not have a caring role for an ill or disabled parent, Carer or sibling
 
Not Stated (PATIENT asked but declined to provide a response)
 
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
|Patient.extension(suggestion of an extension for LOOKED AFTER CHILD INDICATOR)
|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
|Patient.extension(suggestion of an extension for LOOKED AFTER CHILD LEGAL STATUS)
|Section 20 Voluntary Agreement
|
 
Section 31 Care Order
 
Section 38 Interim Care Order
 
Other (not listed)
|-
|-
|EDUCATIONAL ASSESSMENT OUTCOME
|EDUCATIONAL ASSESSMENT OUTCOME
| The outcome of an EDUCATIONAL ASSESSMENT.
| The outcome of an EDUCATIONAL ASSESSMENT.
|R
|R
|Patient.extension(suggestion of an extension for EDUCATIONAL ASSESSMENT OUTCOME)
|No Special Education Needs
|
 
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
|Patient.extension(suggestion of an extension for CHILD PROTECTION PLAN INDICATION CODE)
|Has never been subject to a Child Protection Plan
|
 
Has previously been subject to a Child Protection Plan
 
Is currently subject to a Child Protection Plan
 
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
|Patient.extension(suggestion of an extension for EX-BRITISH ARMED FORCES INDICATOR)
|Ex-services member
|
 
Not an ex-services member or their dependant
 
Dependant of an ex-services member
 
Unknown (PATIENT asked and does not know or is not sure)
 
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
|Patient.extension(suggestion of an extension for OFFENCE HISTORY INDICATION CODE)
|No - No offence
|
 
Yes - Less serious offence
 
Yes - Serious offence
 
Not Known (Not Recorded)
|-
|-
|PRODROME PSYCHOSIS DATE
|PRODROME PSYCHOSIS DATE
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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.).
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
|R
|DetectedIssue.date
Condition.onset[x].onsetDateTime(PRODROME PSYCHOSIS DATE)
|
|
|-
|-
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Such a symptom would be scored 4 or more on the PANSS.
Such a symptom would be scored 4 or more on the PANSS.
|R
|R
|DetectedIssue.date
Condition.onset[x].onsetDateTime(EMERGENT PSYCHOSIS DATE)
|
|
|-
|-
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| 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.
| 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
|R
|DetectedIssue.date
Condition.onset[x].onsetDateTime(MANIFEST PSYCHOSIS DATE)
|
|
|-
|-
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| Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service.
| Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service.
|R
|R
|MedicationRequest.authoredOn
DetectedIssue.mitigation.date
|
|
|-
|-
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Note: For the majority of people this will be the same date as the date of prescription.
Note: For the majority of people this will be the same date as the date of prescription.
|R
|R
|MedicationRequest.authoredOn
DetectedIssue.mitigation.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
|Patient.extension(proposition of an extension for REASONABLE ADJUSTMENT REQUIRED INDICATOR)
|Yes - the patient requires a Reasonable Adjustment
|
 
No - the patient does not require a Reasonable Adjustment
|}<br />
|}<br />


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!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
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|The start date of a Mental Health Care Coordinator Assignment Period for a patient.
|The start date of a Mental Health Care Coordinator Assignment Period for a patient.
|M
|M
|CareTeam.period.start
|
|
|-
|-
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<br />
<br />
|R
|R
|CareTeam.participant.member
|
|
|-
|-
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|The end date of a Mental Health Care Coordinator Assignment Period for a patient.
|The end date of a Mental Health Care Coordinator Assignment Period for a patient.
|R
|R
|CareTeam.period.end
|
|
|-
|-
Line 539: Line 527:
|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
|CareTeam.participant.role
|Day Care Service
|
 
|}<br />
Crisis Resolution Team/Home Treatment Service
 
Primary Care Mental Health Service


=== DisabilityType ===
Community Mental Health Team - Functional
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
| DISABILITY CODE
| The DISABILITY of a PERSON.


This could be where:
Community Mental Health Team - Organic


the PERSON has been diagnosed as disabled or
Assertive Outreach Team


the PERSON considers themself to be disabled.
Community Rehabilitation Service
|M
|Condition.code
|
|-
| 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
|Condition.extension(suggestion of an extension for DISABILITY IMPACT PERCEPTION)
|
|}<br />


=== Care Plan Type ===
General Psychiatry Service
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
| CARE PLAN IDENTIFIER
| A unique identifierfor Care Plan.
|M
|CarePlan.identifier
|
|-
|CARE PLAN TYPE (MENTAL HEALTH)
|The type of Care Plan for the patient, recorded by the service.
|M
|CarePlan.category
|
|-
|CARE PLAN CREATION DATE
|The date that a Care Plan was created for a patient.
|M
|CarePlan.extension(suggestion of an extension for CARE PLAN CREATION DATE)
|
|-
|CARE PLAN CREATION TIME
|The time that a Care Plan was created for a patient.
|R
| CarePlan.extension(suggestion of an extension for CARE PLAN CREATION TIME)
|
|-
|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.
Psychiatric Liaison Service
|R
|CarePlan.extension(suggestion of an extension for CARE PLAN LAST UPDATE DATE)
|
|-
|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.
Psychotherapy Service
|R
 
|CarePlan.extension(suggestion of an extension for CARE PLAN LAST UPDATE TIME)
Psychological Therapy Service (non IAPT)
|
 
|-
Early Intervention Team for Psychosis
| CARE PLAN IMPLEMENTATION DATE
 
|The date that the Care Plan was implemented for a patient.
Young Onset Dementia Team
|R
 
|CarePlan.period.date
Personality Disorder Service
|
 
|}<br />
Memory Services/Clinic/Drop in service


=== Care Plan Agreement ===
Single Point of Access Service
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!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.
24/7 Crisis Response Line
|R
|Consent.actor.role


Consent.actor.reference
Health Based Place Of Safety Service
|
|-
|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.
Crisis Café/Safe Haven/Sanctuary Service
|R
|
|
|-
|CARE PLAN CONTENT AGREED BY
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT.
|M
|Consent.consentingParty
|
|-
|CARE PLAN CONTENT AGREED DATE
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy.
|R
|Consent.dateTime
|
|-
|CARE PLAN CONTENT AGREED TIME
| The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy
|R
| Consent.dateTime
|
|}<br />


=== Assistive Technology to Support Disability Type ===
Walk-in Crisis Assessment Unit Service
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!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
|Device.extension(suggestion of an extension for ASSISTIVE TECHNOLOGY FINDING (SNOMED CT))
|
|-
|PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY)
|The date, time and time zone for the prescription of Assistive Technology.
|R
|DeviceRequest.authoredOn


OR
Psychiatric Decision Unit Service


Device.extension(suggestion of an extension for PRESCRIPTION TIMESTAMP ASSISTIVE TECHNOLOGY)
Acute Day Service
|
|}<br />


=== Social and Personal Circumstances ===
Crisis House Service
{| class="wikitable"
 
!Name
Forensic Mental Health Service
!Description
 
!Conformance
Forensic Learning Disability Service
!FHIR STU3 Mapping
 
!Value Set
Autism Service
|-
 
|SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
Specialist Perinatal Mental Health Community Service
|The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person.
 
|M
Neurodevelopment Team
|
 
|
Paediatric Liaison Service
|-
 
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP
Looked After Children Service
|The date, time and time zone on which the Social and Personal Circumstance was recorded.
|R
|
|
|}<br />


=== Overseas Visitor Charging Category ===
Youth Offending Service
{| class="wikitable"
 
!Name
Acquired Brain Injury Service
!Description
 
!Conformance
Community Eating Disorder Service
!FHIR STU3 Mapping
 
!Value Set
Substance Misuse Team
|-
 
|OVERSEAS VISITOR CHARGING CATEGORY
Criminal Justice Liaison and Diversion Service
|The charging category relating to an OVERSEAS VISITOR STATUS.
 
|M
Prison Psychiatric Inreach Service
|
 
|
Asylum Service
|-
 
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE
Individual Placement and Support Service
|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
Mental Health In Education Service
|
|
|-
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until.
|R
|
|
|}<br />


=== Mental Health Currency Model ===
Problem Gambling Service
{| class="wikitable"
 
!Name
Rough Sleeping Service
!Description
 
!Conformance
Community Team for Learning Disabilities
!FHIR STU3 Mapping
 
!Value Set
Epilepsy/Neurological Service
|-
 
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT)
Specialist Parenting Service
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type.
 
|P
Enhanced/Intensive Support Service
|
 
|
Mental Health Support Team
|-
 
|START DATE (MENTAL HEALTH RESOURCE GROUP)
Maternal Mental Health Service
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group
 
|P
Mental Health Services for Deaf people
|
 
|
Veterans Complex Treatment Service
|-
 
|END DATE (MENTAL HEALTH RESOURCE GROUP)
Enhanced care in care homes teams
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service.
 
|P
Mental Health and Wellbeing Hubs
|
 
|
Other Mental Health Service - in scope of National Tariff Payment System
 
Other Mental Health Service - out of scope of National Tariff Payment System
|}<br />
|}<br />


=== Service or Team Referral ===
=== DisabilityType ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|SERVICE REQUEST IDENTIFIER
| DISABILITY CODE
|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 DISABILITY of a PERSON.
 
This could be where:
 
the PERSON has been diagnosed as disabled or
 
the PERSON considers themself to be disabled.
|M
|M
|
|Behaviour and Emotional
|
 
Hearing
 
Manual Dexterity
 
Memory or ability to concentrate, learn or understand (Learning Disability)
 
Mobility and Gross Motor
 
Perception of Physical Danger
 
Personal, Self Care and Continence
 
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
 
Sight
 
Speech
 
Other (not listed)
 
No Disability
 
Not Stated (Person asked but declined to provide a response)
|-
|-
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
| DISABILITY IMPACT PERCEPTION
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care.
|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.
|M
|R
|
|Yes – limited a lot
|
 
Yes – limited a little
 
No - not limited
 
Prefer not to say (Patient asked but declined to provide a response)
|}<br />
 
=== Care Plan Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|REFERRAL REQUEST RECEIVED DATE
| CARE PLAN IDENTIFIER
|This is the date the REFERRAL REQUEST was received by the Health Care Provider.
| A unique identifierfor Care Plan.
|M
|M
|
|
|-
|CARE PLAN TYPE (MENTAL HEALTH)
|The type of Care Plan for the patient, recorded by the service.
|M
|Mental Health Care Plan
Urgent and Emergency Mental Health Care Plan
Mental Health Crisis Plan
Positive Behaviour Support Plan
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
|
|
|-
|-
|REFERRAL REQUEST RECEIVED TIME
|CARE PLAN CREATION 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.
|The time that a Care Plan was created for a patient.
|R
|R
|
|
|
|-
|-
|NHS SERVICE AGREEMENT LINE NUMBER
|CARE PLAN LAST UPDATED 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.
|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
|R
|
|
|
|-
|-
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
|CARE PLAN LAST UPDATED 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.
|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
|
|
|
|-
|-
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET
| CARE PLAN IMPLEMENTATION DATE
|The source of referral to a Mental Health Service.
|The date that the Care Plan was implemented for a patient.
|R
|R
|
|
|
|}<br />
 
=== Care Plan Agreement ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|ORGANISATION IDENTIFIER (REFERRING)
|FAMILY INVOLVED IN CARE PLAN INDICATOR
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust.
|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
|R
|
|Yes - a member of the patient's family is currently involved in the patient's care plan
|
 
No - a member of the patient's family is not currently involved in the patient's care plan
 
Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN
|-
|-
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|FAMILY NOT INVOLVED IN CARE PLAN REASON
|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 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
|R
|
|At the request of the patient
|
 
Access restrictions on the family
 
No known family
 
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
|-
|-
|CLINICAL RESPONSE PRIORITY TYPE
|CARE PLAN CONTENT AGREED DATE
|The clinical response priority of a SERVICE REQUEST.
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy.
|R
|R
|
|
|
|-
|-
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
|CARE PLAN CONTENT AGREED TIME
|This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service
| The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy
|R
|R
|
|
|
|}<br />
 
=== Assistive Technology to Support Disability Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH)
|ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
|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.
|The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on.
|R
|M
|
|
|
|-
|-
|DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT)
|PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY)
|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 date, time and time zone for the prescription of Assistive Technology.
|R
|R
|
|
|}<br />
=== Social and Personal Circumstances ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|
|-
|-
|DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT)
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP
|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>
|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
!Value Set
|-
|OVERSEAS VISITOR CHARGING CATEGORY
|The charging category relating to an OVERSEAS VISITOR STATUS.
|M
|Standard NHS-funded PATIENT
 
Immigration Health Surcharge payee
 
Charge-exempt Overseas Visitor (European Economic Area)
 
Chargeable European Economic Area PATIENT
 
Charge-exempt Overseas Visitor (non-European Economic Area)
 
Chargeable non-European Economic Area PATIENT
 
Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY
 
OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded)
|-
|-
|DISCHARGE PLAN CREATION DATE
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE
|The date that a Discharge Plan was created for a patient.
|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
|
|
|
|-
|-
|DISCHARGE PLAN CREATION TIME
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE
|The time that a Discharge Plan was created for a patient.
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until.
|R
|R
|
|
|
|}<br />
 
=== Mental Health Currency Model ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|DISCHARGE PLAN LAST UPDATED DATE
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT)
|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.
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type.
|R
|P
|
|
|
|-
|-
|DISCHARGE PLAN LAST UPDATED TIME
|START DATE (MENTAL HEALTH RESOURCE GROUP)
|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.
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group
|R
|P
|
|
|
|-
|-
|SERVICE DISCHARGE DATE
|END DATE (MENTAL HEALTH RESOURCE GROUP)
|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.
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service.
|R
|P
|
|
|-
|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
|
|
|
|}<br />
|}<br />


=== Other Reason for Referral ===
=== Service or Team Referral ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|OTHER REASON FOR REFERRAL (MENTAL HEALTH)
|SERVICE REQUEST IDENTIFIER
|The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service.
|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
|M
|
|
|
|}<br />
=== Service or Team Type Referred To ===
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
|-
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care.
|R
|M
|
|
|
|-
|-
|SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
|REFERRAL REQUEST RECEIVED DATE
|The type of service or team within a Mental Health Service that a patient was referred to
|This is the date the REFERRAL REQUEST was received by the Health Care Provider.
|M
|M
|
|
|
|-
|-
|REFERRAL CLOSURE DATE
|REFERRAL REQUEST RECEIVED TIME
|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.
|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
|
|
|
|-
|-
|REFERRAL CLOSURE TIME
|NHS SERVICE AGREEMENT LINE NUMBER
|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.
|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
|
|
|
|-
|-
|REFERRAL REJECTION DATE
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
|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.
|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
|
|
|
|-
|-
|REFERRAL REJECTION TIME
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET
|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.
|The source of referral to a Mental Health Service.
|R
|R
|
|Primary Health Care: General Medical Practitioner Practice
|
 
|-
Primary Health Care: Health Visitor
|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.
Other Primary Health Care
|R
 
|
Primary Health Care: Maternity Service
|
|-
|REFERRAL REJECTION REASON
|The reason that a Referral Request has been rejected by the SERVICE.
|R
|
|
|}<br />


=== Referral to Treatment (RTT) ===
Self-Referral: Self
{| class="wikitable"
 
!Name
Self-Referral: Carer/Relative
!Description
 
!Conformance
Local Authority and Other Public Services: Social Services
!FHIR STU3 Mapping
 
!Value Set
Local Authority and Other Public Services: Education Service / Educational Establishment
|-
 
|PATIENT PATHWAY IDENTIFIER
Local Authority and Other Public Services: Housing Service
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY.
 
|R
Employer
|
 
|
Employer: Occupational Health
|-
 
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
Justice System: Police
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER.
 
|R
Justice System: Courts
|
 
|
Justice System: Probation Service
 
Justice System: Prison
 
Justice System: Court Liaison and Diversion Service
 
Justice System: Youth Offending Team
 
Child Health: School Nurse
 
Child Health: Hospital-based Paediatrics
 
Child Health: Community-based Paediatrics
 
Independent sector - Medium Secure Inpatients
 
Independent Sector - Low Secure Inpatients
 
Other Independent Sector Mental Health Services
 
Voluntary Sector
 
Acute Secondary Care: Emergency Care Department
 
Other secondary care specialty
 
Temporary transfer from another Mental Health NHS Trust
 
Permanent transfer from another Mental Health NHS Trust
 
Other: Asylum Services
 
Other: Telephone or Electronic Access Service
 
Other: Out of Area Agency
 
Other: Drug Action Team / Drug Misuse Agency
 
Other: Jobcentre Plus
 
Other SERVICE or agency
 
Other: Single Point of Access Service
 
Other: Urgent and Emergency Care Ambulance Service
 
Improving Access to Psychological Therapies Service
 
Internal Referral
 
Mental Health Drop In Service
|-
|-
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH)
|ORGANISATION IDENTIFIER (REFERRING)
|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.
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust.
|M
|
|
|-
|REFERRAL TO TREATMENT PERIOD START DATE
|The start date of a REFERRAL TO TREATMENT PERIOD.
|R
|R
|
|
|
|-
|-
|REFERRAL TO TREATMENT PERIOD END DATE
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|The end date of a REFERRAL TO TREATMENT PERIOD.
|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
|R
|
|Art Therapist
|
 
|-
Clinical Psychologist
|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.
Dietitian
|R
 
|
Dramatherapist
|
 
|}<br />
Music Therapist
 
Occupational Therapist
 
Orthotist
 
Physiotherapist
 
Podiatrist
 
Prosthetist
 
Psychotherapist
 
Radiographer
 
Speech and Language Therapist
 
Orthoptist


=== Onward Referral ===
Community Dentist
{| class="wikitable"
 
!Name
Consultant
!Description
 
!Conformance
General Medical Practitioner
!FHIR STU3 Mapping
 
!Value Set
General Practitioner with an Extended Role (GPwER)
|-
 
|DECISION TO REFER DATE (ONWARD REFERRAL)
Midwife
|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
District Nurse
|
 
|
Health Visitor
|-
 
|DECISION TO REFER TIME (ONWARD REFERRAL)
Macmillan Nurse
|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
School Nurse
|
 
|
Specialist Nursing - Active Case Management (Community Matrons)
|-
 
|ONWARD REFERRAL DATE
Specialist Nursing - Arthritis Nursing/Liaison
|The date the patient was referred to another service, which may be in the same or a different organisation.
 
|M
Specialist Nursing - Asthma and Respiratory Nursing/Liaison
|
 
|
Specialist Nursing - Breast Care Nursing/Liaison
|-
 
|ONWARD REFERRAL TIME
Specialist Nursing - Cancer Related
|The time the patient was referred to another service, which may be in the same or a different organisation.
 
|R
Specialist Nursing - Cardiac Nursing/Liaison
|
 
|
Specialist Nursing - Children's Services
|-
 
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET)
Specialist Nursing - Community Cystic Fibrosis
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation.
 
|R
Specialist Nursing - Continence Services
|
 
|
Specialist Nursing - Diabetic Nursing/Liaison
|-
 
|REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH)
Specialist Nursing - Enteral Feeding Nursing Services
|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
Specialist Nursing - Haemophilia Nursing Services
|
 
|
Specialist Nursing - Infectious Diseases
|-
 
|ORGANISATION IDENTIFIER (RECEIVING)
Specialist Nursing - Intensive Care Nursing
|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
|
|
|}<br />


=== Discharge Plan Agreement ===
Specialist Nursing - Palliative/Respite Care
{| class="wikitable"
 
!Name
Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison
!Description
 
!Conformance
Specialist Nursing - Rehabilitation Nursing
!FHIR STU3 Mapping
 
!Value Set
Specialist Nursing - Stoma Care Services
|-
 
|DISCHARGE PLAN CONTENT AGREED BY
Specialist Nursing - Tissue Viability Nursing/Liaison
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT.
 
|M
Specialist Nursing - Transplantation Patients Nursing Services
|
 
|
Specialist Nursing - Treatment Room Nursing Services
|-
 
|DISCHARGE PLAN CONTENT AGREED DATE
Specialist Nursing - Tuberculosis Specialist Nursing
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
 
|R
Specialist Nursing - Other Specialist Nursing
|
|
|-
|DISCHARGE PLAN CONTENT AGREED TIME
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|R
|
|
|}<br />


=== Medication Prescription ===
Specialist Nursing - Safeguarding
{| class="wikitable"
 
!Name
Practice Nursing
!Description
 
!Conformance
Staff Nurse
!FHIR STU3 Mapping
 
!Value Set
Other Registered Nurse
 
Public Health Nurse
 
Appliances Technician
 
Audiologist
 
Counsellor
 
Nursery Nurse
 
Play Therapist
 
Social Worker
 
Voluntary Care Worker
 
Screener (in a National Screening Programme)
 
Other Care Professional (not listed)
|-
|-
|PRESCRIPTION IDENTIFIER
|CLINICAL RESPONSE PRIORITY TYPE
|The unique identifier of a PRESCRIPTION.
|The clinical response priority of a SERVICE REQUEST.
|P
|R
|
|Emergency
|
 
Urgent/Serious
 
Routine
 
Very Urgent
|-
|-
|PRESCRIPTION DATE (MEDICATION)
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
|The date 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
|
|(Suspected) First Episode Psychosis
|
 
|-
Ongoing or Recurrent Psychosis
|PRESCRIPTION TIME (MEDICATION)
 
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
Bi polar disorder
|P
 
|
Depression
|
 
|}<br />
Anxiety
 
Obsessive compulsive disorder
 
Phobias
 
Organic brain disorder
 
Drug and alcohol difficulties
 
Unexplained physical symptoms
 
Post-traumatic stress disorder
 
Eating disorders
 
Perinatal mental health issues


=== Care Contact ===
Personality disorders
{| class="wikitable"
 
!Name
Self harm behaviours
!Description
 
!Conformance
Conduct disorders
!FHIR STU3 Mapping
 
!Value Set
In crisis
|-
 
|CARE CONTACT IDENTIFIER
Relationship difficulties
|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
Gender Discomfort issues
|
 
|
Attachment difficulties
 
Self - care issues
 
Adjustment to health issues
 
Neurodevelopmental Conditions, excluding Autism
 
Suspected Autism
 
Diagnosed Autism
 
Preconception perinatal mental health concern
 
Gambling disorder
 
Community Perinatal Mental Health Partner Assessment
 
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
|Unavailability of bed at referring organisation
 
Safeguarding
 
Offending restrictions
 
Staff member or family/friend within the referring organisation
 
Patient choice
 
Patient away from home
 
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
!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
|
|(Suspected) First Episode Psychosis
|
 
|-
Ongoing or Recurrent Psychosis
|PLACE OF SAFETY INDICATOR
 
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY.
Bi polar disorder
|R
 
|
Depression
|
 
Anxiety
 
Obsessive compulsive disorder
 
Phobias
 
Organic brain disorder
 
Drug and alcohol difficulties
 
Unexplained physical symptoms
 
Post-traumatic stress disorder
 
Eating disorders
 
Perinatal mental health issues
 
Personality disorders
 
Self harm behaviours
 
Conduct disorders
 
In crisis
 
Relationship difficulties
 
Gender Discomfort issues
 
Attachment difficulties
 
Self - care issues
 
Adjustment to health issues
 
Neurodevelopmental Conditions, excluding Autism
 
Suspected Autism
 
Diagnosed Autism
 
Preconception perinatal mental health concern
 
Gambling disorder
 
Community Perinatal Mental Health Partner Assessment
 
Behaviours that challenge due to a Learning Disability
|}<br />
 
=== Service or Team Type Referred To ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|Day Care Service
|
 
|-
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.
Primary Care Mental Health Service
|R
 
|
Community Mental Health Team - Functional
|
 
|-
Community Mental Health Team - Organic
|CARE CONTACT PATIENT THERAPY MODE
 
|The mode of therapy for the patient during a Care Contact.
Assertive Outreach Team
|R
 
|
Community Rehabilitation Service
|
 
|-
General Psychiatry 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.
Psychiatric Liaison Service
|R
 
|
Psychotherapy Service
|
 
|-
Psychological Therapy Service (non IAPT)
|EARLIEST REASONABLE OFFER DATE
 
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission.
Early Intervention Team for Psychosis
|R
 
|
Young Onset Dementia Team
|
 
|-
Personality Disorder Service
|EARLIEST CLINICALLY APPROPRIATE DATE
 
|The earliest DATE that it was clinically appropriate for an ACTIVITY to take place.
Memory Services/Clinic/Drop in service
 
Single Point of Access Service
 
24/7 Crisis Response Line
 
Health Based Place Of Safety Service
 
Crisis Café/Safe Haven/Sanctuary Service
 
Walk-in Crisis Assessment Unit Service
 
Psychiatric Decision Unit Service
 
Acute Day Service
 
Crisis House Service
 
Forensic Mental Health Service
 
Forensic Learning Disability Service
 
Autism Service
 
Specialist Perinatal Mental Health Community Service
 
Neurodevelopment Team
 
Paediatric Liaison Service
 
Looked After Children Service
 
Youth Offending Service
 
Acquired Brain Injury Service
 
Community Eating Disorder Service
 
Substance Misuse Team
 
Criminal Justice Liaison and Diversion Service
 
Prison Psychiatric Inreach Service
 
Asylum Service
 
Individual Placement and Support Service
 
Mental Health In Education Service
 
Problem Gambling Service
 
Rough Sleeping Service
 
Community Team for Learning Disabilities
 
Epilepsy/Neurological Service
 
Specialist Parenting Service
 
Enhanced/Intensive Support Service
 
Mental Health Support Team
 
Maternal Mental Health Service
 
Mental Health Services for Deaf people
 
Veterans Complex Treatment Service
 
Enhanced care in care homes teams
 
Mental Health and Wellbeing Hubs
 
Other Mental Health Service - in scope of National Tariff Payment System
 
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
|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
|
|
|-
|-
|CARE CONTACT CANCELLATION DATE
|REFERRAL REJECTION DATE
|The date that a Care Contact was cancelled by the Provider or Patient.
|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
|
|
|
|-
|-
|CARE CONTACT CANCELLATION REASON
|REFERRAL REJECTION TIME
|The reason that a Care Contact was cancelled.
|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
|
|
|
|-
|-
|REASONABLE ADJUSTMENT MADE INDICATOR
|REFERRAL CLOSURE REASON
|Was a reasonable adjustment made for this patient?
|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
|Admitted elsewhere (at the same or other Health Care Provider)
 
Treatment completed
 
Moved out of the area
 
No further treatment appropriate
 
Patient did not attend
 
Patient died
 
Patient requested discharge
 
Referred to other specialty/Service (at the same or other Health Care Provider)
 
PATIENT refused to be seen
|-
|REFERRAL REJECTION REASON
|The reason that a Referral Request has been rejected by the SERVICE.
|R
|R
|
|Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider)
|
 
Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider)
 
Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST)
|}<br />
|}<br />


=== Care Activity ===
=== Referral to Treatment (RTT) ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|CARE ACTIVITY IDENTIFIER
|PATIENT PATHWAY 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.
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY.
|M
|R
|
|
|
|-
|-
|CLINICAL CONTACT DURATION OF CARE ACTIVITY
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
|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.
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER.
|R
|R
|
|
|
|-
|-
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH)
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.
|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.
|R
|M
|
|Allied Health Professional Referral To Treatment Measurement
|
 
Other Referral To Treatment Measurement Type (not listed)
|-
|-
|FINDING SCHEME IN USE (MENTAL HEALTH)
|REFERRAL TO TREATMENT PERIOD START DATE
|The code scheme basis of a finding.
|The start date of a REFERRAL TO TREATMENT PERIOD.
|R
|R
|
|
|
|-
|-
|CODED FINDING (CODED CLINICAL ENTRY)
|REFERRAL TO TREATMENT PERIOD END DATE
|A unique identifier for a finding from a specific classification or clinical terminology.
|The end date of a REFERRAL TO TREATMENT PERIOD.
|R
|R
|
|
|
|-
|-
|CODED OBSERVATION (SNOMED CT)
|REFERRAL TO TREATMENT PERIOD STATUS
|A unique identifier for an observation from a specific clinical terminology.
|The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL.
|R
|R
|
|First activity in a Referral to Treatment Period
|
 
|-
First activity at the start of a new Referral to Treatment Period following Active Monitoring
|OBSERVATION VALUE
 
|The numeric value resulting from a clinical observation.
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
|R
 
|
Subsequent activity during a Referral to Treatment Period - further activities anticipated
|
 
|-
Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated
|UCUM UNIT OF MEASUREMENT
 
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>.
End of the Referral to Treatment Period: Start of First Definitive Treatment
|R
 
|
End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient
|
 
End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional
 
End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral
 
End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required
 
End of the Referral to Treatment Period: patient declined offered treatment
 
End of the Referral to Treatment Period: patient died before treatment
 
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)
 
Not part of a Referral to Treatment Period: Care activity during Active Monitoring
 
Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral
 
Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods
 
Referral to Treatment Period status not yet known
|}<br />
|}<br />


=== Other in Attendance ===
=== Onward Referral ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT
|DECISION TO REFER DATE (ONWARD REFERRAL)
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT.
|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
|R
|
|
|
|-
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE
|DECISION TO REFER TIME (ONWARD REFERRAL)
|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
|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
|
|
|
|-
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE
|ONWARD REFERRAL 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 date the patient was referred to another service, which may be in the same or a different organisation.
|R
|
|
|}<br />
 
=== Indirect Activity ===
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
|INDIRECT ACTIVITY DATE
|The date that the indirect activity took place
|M
|M
|
|
|
|-
|-
|INDIRECT ACTIVITY TIME
|ONWARD REFERRAL TIME
|The time that the indirect activity took place
|The time the patient was referred to another service, which may be in the same or a different organisation.
|R
|R
|
|
|
|-
|-
|DURATION OF INDIRECT ACTIVITY
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET)
|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.
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation.
|R
|Transfer of Clinical Responsibility
 
For Opinion Only
 
For Diagnostic Test Only
 
New Referral (Non Transfer)
 
Other (not listed)
 
Onward Referral Reason Not Applicable
 
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
|Unavailability of bed at referring organisation
 
Safeguarding
 
Offending restrictions
 
Staff member or family/friend within the referring organisation
 
Patient choice
 
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
|R
|
|
|
|-
|-
|CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|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 the capture of indirect activity to be attributed.
|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 />


=== Group Session ===
=== Discharge Plan Agreement ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|GROUP SESSION IDENTIFIER
|DISCHARGE PLAN CONTENT AGREED BY
|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.
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT.
|M
|M
|
|Patient or Patient Proxy
|
 
Advocate
 
Clinical Service or Team
 
Local Community Support Team
 
Current Commissioner
 
Commissioner of Planned Discharge Destination
 
Family member or carer with parental responsibility
 
Family member or carer without parental responsibility
|-
|-
|GROUP SESSION DATE
|DISCHARGE PLAN CONTENT AGREED DATE
|The date that a Group Session took place, or, if cancelled, was scheduled to take place.
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|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)
|DISCHARGE PLAN CONTENT AGREED TIME
|The type of Group Session provided by a Mental Health Service.
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|R
|
|
|-
|NUMBER OF GROUP SESSION PARTICIPANTS
|The number of persons who participated in the Group Session excluding the care professionals.
|R
|R
|
|
|
|}<br />
|}<br />


=== Mental Health Drop In Contact ===
=== Medication Prescription ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!Value Set
|-
|-
|MENTAL HEALTH DROP IN CONTACT IDENTIFIER
|PRESCRIPTION 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.
|The unique identifier of a PRESCRIPTION.
|M
|P
|
|
|-
|PRESCRIPTION DATE (MEDICATION)
|The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|P
|
|
|-
|-
|CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT)
|PRESCRIPTION TIME (MEDICATION)
|The date that a Drop In Contact took place.
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|P
|
|}<br />
 
=== Care Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|M
|
|
|
|-
|-
|MENTAL HEALTH DROP IN CONTACT SERVICE TYPE
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|The type of SERVICE where the Mental Health Drop In Contact took place.
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|R
|R
|
|
|
|-
|-
|START TIME (MENTAL HEALTH DROP IN CONTACT)
|CARE CONTACT DATE
|The Start Time of the Mental Health Drop In Contact as reported by the Care Professional.
|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
|R
|
|
|
|-
|-
|END TIME (MENTAL HEALTH DROP IN CONTACT)
|ADMINISTRATIVE CATEGORY CODE
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional.
|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
|
|NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)
|
 
|}<br />
Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006
 
Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006
 
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.
 
Not applicable


=== Mental Health Act Legal Status Classification Assignment Period ===
ADMINISTRATIVE CATEGORY CODE not known
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
|CLINICAL CONTACT DURATION OF CARE CONTACT
|A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period.
|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.
|M
|R
|
|
|
|-
|-
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|CONSULTATION TYPE
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period.
|The type of consultation between the CARE PROFESSIONAL and the PATIENT.
|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
|R
|
|Initial Consultation
|
 
Follow-up Consultation
|-
|-
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|CARE CONTACT SUBJECT
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|The person who was the subject of the Care Contact.
|R
|R
|
|Patient
|
 
Patient Proxy
|-
|-
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|CONSULTATION MECHANISM (MENTAL HEALTH)
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|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
|
|Face to face
|
 
Telephone
 
Talk type for a person unable to speak
 
Email
 
Text Message (Asynchronous)
 
Instant messaging (Synchronous)
 
Video consultation
 
Message Board (Asynchronous)
 
Chat Room (Synchronous)
 
Other (not listed)
|-
|-
|END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|ACTIVITY LOCATION TYPE CODE
|The date on which the Mental Health Act Legal Status Classification Assignment Period ended.
|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
|
|Patient's home
|
 
|-
Carer's home
|END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
 
|The time on which the Mental Health Act Legal Status Classification Period ended.
Patient's workplace
|R
 
|
Other patient related location
|
 
|-
Primary Care Health Centre
|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.
Polyclinic
|R
 
|
General Medical Practitioner Practice
|
 
|-
Dental Practice
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
 
|'A code to identify the classification of Mental Health Act Legal Status.
Ophthalmic Medical Practitioner premises
|R
 
|
Walk In Centre
|
 
|-
Out of Hours Centre
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY
 
|The primary reason for the detention of PATIENTS.
Emergency Community Dental Service
|R
 
|
Out-Patient Clinic
|
 
|}<br />
Ward
 
Day Hospital
 
Emergency Care Department or Minor Injuries Department
 
Other departments
 
Hospice
 
Care Home Without Nursing


=== Mental Health Responsible Clinician Assignment Period ===
Care Home With Nursing
{| class="wikitable"
 
!Name
Children’s Home
!Description
 
!Conformance
Integrated Care Home Without Nursing and Care Home With Nursing
!FHIR STU3 Mapping
 
!Value Set
Day Centre
|-
 
|START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
Resource Centre
|The start date of an assignment of a Mental Health Responsible Clinician to a patient.
 
|M
Sure Start Children’s Centre
|
 
|
Child Development Centre
|-
 
|END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
School
|The end date of an assignment of a Mental Health Responsible Clinician to a patient.
 
|R
Further Education College
|
 
|
University
|}<br />
 
Nursery Premises
 
Other Childcare Premises
 
Training Establishments


=== Conditional Discharge ===
Other Educational Premises
{| class="wikitable"
 
!Name
Prison
!Description
 
!Conformance
Probation Service Premises
!FHIR STU3 Mapping
 
!Value Set
Police Station / Police Custody Suite
|-
 
|START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
Young Offender Institution
|The start date of the Mental Health Conditional Discharge Period.
 
|M
Young Offender Institution (15-17)
|
 
|
Young Offender Institution (18-21)
 
Immigration Removal Centre
 
Street or other public open space
 
Other publicly accessible area or building
 
Voluntary or charitable agency premises
 
Dispensing Optician premises
 
Dispensing Pharmacy premises
 
Other locations not elsewhere classified
 
General Health Promotion Session
 
Telephone Support Sessiom
 
Thereputic Group Session
|-
|-
|END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
|PLACE OF SAFETY INDICATOR
|The end date of the Mental Health Conditional Discharge Period.
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY.
|R
|R
|
|Yes – is being used as a Place of Safety
|
 
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
|
|Yes - a Community Perinatal Mental Health Partner Assessment has been offered
|
|}<br />


=== Community Treatment Order Recall ===
No - a Community Perinatal Mental Health Partner Assessment has not been offered
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!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
|R
|
|Yes - the care contact is a result of a planned Appointment
|
 
No - the care contact is not a result of a planned appointment
|-
|-
|EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL)
|CARE CONTACT PATIENT THERAPY MODE
|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
|The mode of therapy for the patient during a Care Contact.
|R
|R
|
|Individual patient
|
 
Couple
 
Group Therapy
|-
|-
|END DATE (COMMUNITY TREATMENT ORDER RECALL)
|ATTENDED OR DID NOT ATTEND CODE
|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).
|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
|R
|
|Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT
|
 
Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen
 
Patient arrived late and could not be seen
 
APPOINTMENT cancelled by, or on behalf of, the PATIENT
 
Did not attend - no advance warning given
 
Appointment cancelled or postponed by the health care provider
|-
|-
|COMMUNITY TREATMENT ORDER END REASON
|EARLIEST REASONABLE OFFER DATE
|The reason for the termination of a period of a Community Treatment Order.
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission.
|R
|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
|Cancelled for Clinical Reasons
Cancelled for Non-clinical Reasons
|-
|REASONABLE ADJUSTMENT MADE INDICATOR
|Was a reasonable adjustment made for this patient?
|R
|Yes - a Reasonable Adjustment was made for the patient
No - a Reasonable Adjustment was not made for the patient
Not applicable
|}<br />
|}<br />


=== Community Treatment Order Recall ===
=== Care Activity ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!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
|
|
|-
|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
|
|
|-
|-
|END TIME (COMMUNITY TREATMENT ORDER RECALL)
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|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 SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.
|R
|R
|
|
|
|-
|}<br />
|FINDING SCHEME IN USE (MENTAL HEALTH)
|The code scheme basis of a finding.
|R
|ICD-10


=== Hospital Provider Spell ===
SNOMED CT®
{| class="wikitable"
!Name
!Description
!Conformance
!FHIR STU3 Mapping
!Value Set
|-
|-
|HOSPITAL PROVIDER SPELL IDENTIFIER
|CODED FINDING (CODED CLINICAL ENTRY)
|A unique identifier for each Hospital Provider Spell for a Health Care Provider.
|A unique identifier for a finding from a specific classification or clinical terminology.
|M
|R
|
|
|
|-
|-
|DECIDED TO ADMIT DATE
|CODED OBSERVATION (SNOMED CT)
|The date a DECISION TO ADMIT was made.
|A unique identifier for an observation from a specific clinical terminology.
|R
|R
|
|
|
|-
|-
|DECIDED TO ADMIT TIME
|OBSERVATION VALUE
|The time a DECISION TO ADMIT was made.
|The numeric value resulting from a clinical observation.
|R
|R
|
|
|
|-
|-
|START DATE (HOSPITAL PROVIDER SPELL)
|UCUM UNIT OF MEASUREMENT
|The start date of a Hospital Provider Spell.
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>.
|M
|
|
|-
|START TIME (HOSPITAL PROVIDER SPELL)
|The start time of a Hospital Provider Spell.
|R
|R
|
|
|
|}<br />
 
=== Other in Attendance ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|-
|ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT
|The source of admission to a Hospital Provider Spell.
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT.
|R
|M
|
|Independent Advocate (Family Member)
|
 
Independent Advocate (Independent Person)
 
Independent Mental Capacity Advocate (IMCA)
 
Independent Mental Health Advocate (IMHA)
 
Non-Instructed Advocate
 
Parent or relative (Non-Advocate)
 
Friend or neighbour (Non-Advocate)
 
Care Worker (Non-Advocate)
|-
|-
|METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE
|The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission.
|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
|
|PATIENT has chosen not to have an Independent Mental Health Advocate
|
 
No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken
 
No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought
 
No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken
 
No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought
 
Other (not listed)
 
Not applicable (no requirement for an Independent Mental Capacity Advocate)
|-
|-
|POSTCODE OF MAIN VISITOR
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH 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 Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|R
|
|Patient has chosen not to have an Independent Mental Health Advocate
|
 
|-
No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken
|ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
 
|The estimated discharge date from a Hospital Provider Spell.
No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought
|R
 
|
No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken
|
 
No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought
 
Other (not listed)
 
Not applicable (no requirement for an Independent Mental Health Advocate)
|}<br />
 
=== Indirect Activity ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
!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
|
|
|-
|-
|METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|GROUP SESSION DATE
|The method of discharge from a Hospital Provider Spell.
|The date that a Group Session took place, or, if cancelled, was scheduled to take place.
|R
|M
|
|
|
|-
|-
|DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|CLINICAL CONTACT DURATION OF GROUP SESSION
|The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died.
|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
|
|
|
|-
|-
|POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)
|GROUP SESSION TYPE (MENTAL HEALTH)
|The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell.
|The type of Group Session provided by a Mental Health Service.
|R
|R
|
|General Health Promotion Session
|
 
Telephone Support Session
 
Therapeutic Group Session
|-
|-
|TRANSFORMING CARE INDICATOR
|NUMBER OF GROUP SESSION PARTICIPANTS
|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 number of persons who participated in the Group Session excluding the care professionals.
|R
|R
|
|
|-
|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
|
|
|
|}<br />
|}<br />


=== Ward Stay ===
=== Mental Health Drop In Contact ===
{| class="wikitable"
{| class="wikitable"
!Name
!Name
!Description
!Description
!Conformance
!Conformance
!FHIR STU3 Mapping
!Value Set
!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
|Memory Services/Clinic/Drop In Service
 
24/7 Crisis Response Line
 
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
|R
|
|
|
|-
|-
|END DATE (MENTAL HEALTH TRIAL LEAVE)
|END TIME (MENTAL HEALTH DROP IN CONTACT)
|The End Date of a period of Mental Health Trial Leave for a PATIENT.
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|R
|
|
|}<br />
=== Mental Health Act Legal Status Classification Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|
|-
|-
|END DATE (WARD STAY)
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The end date of a ward stay.
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period.
|R
|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
|
|
|-
|-
|END TIME (WARD STAY)
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON
|The end time of a ward stay.
|The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period.
|R
|R
|
|Change in Mental Health Act Legal Status Classification Code (including from informal)
|
 
Transfer from other Health Care Provider
|-
|-
|WARD SETTING TYPE (MENTAL HEALTH)
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell.
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|R
|
|
|-
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|
|
|-
|-
|INTENDED AGE GROUP (MENTAL HEALTH)
|END 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 date on which the Mental Health Act Legal Status Classification Assignment Period ended.
|R
|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
|
|
|-
|-
|SEX OF PATIENTS CODE (MENTAL HEALTH)
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON
|The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed.
|The reason for the end of the Mental Health Act Legal Status Classification Assignment Period.
|R
|Change in Mental Health Act Legal Status Classification Code (including to informal)
 
Transfer to other Health Care Provider
 
Death of patient
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
|'A code to identify the classification of Mental Health Act Legal Status.
|R
|Informal
 
Formally detained under Mental Health Act Section 2
 
Formally detained under Mental Health Act Section 3
 
Formally detained under Mental Health Act Section 4
 
Formally detained under Mental Health Act Section 5 (2)
 
Formally detained under Mental Health Act Section 5 (4)
 
Formally detained under Mental Health Act Section 35
 
Formally detained under Mental Health Act Section 36
 
Formally detained under Mental Health Act Section 37 with section 41 restrictions
 
Formally detained under Mental Health Act Section 37
 
Formally detained under Mental Health Act Section 38
 
Formally detained under Mental Health Act Section 44
 
Formally detained under Mental Health Act Section 46
 
Formally detained under Mental Health Act Section 47 with section 49 restrictions
 
Formally detained under Mental Health Act Section 47
 
Formally detained under Mental Health Act Section 48 with section 49 restrictions
 
Formally detained under Mental Health Act Section 48
 
Formally detained under Mental Health Act Section 135
 
Formally detained under Mental Health Act Section 136
 
Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991
 
Formally detained under other acts
 
Subject to guardianship under Mental Health Act Section 7
 
Subject to guardianship under Mental Health Act Section 37
 
Formally detained under Mental Health Act Section 45A (Limited direction in force)
 
Formally detained under Mental Health Act Section 45A (Limitation direction ended)
 
Not Applicable
 
Not Known
|-
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY
|The primary reason for the detention of PATIENTS.
|R
|Mental disorder (Learning Disability not present or not primary reason for using Act)
 
Mental disorder (Learning Disability primary reason for using Act)
 
Not applicable (i.e. not detained)
 
Not Known (Not Recorded)
|}<br />
 
=== Mental Health Responsible Clinician Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}<br />
 
=== Conditional Discharge ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Mental Health absolute discharge
 
Recall of PATIENT
 
Death of PATIENT
|-
|MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY
|The body or PERSON responsible for granting Mental Health Absolute Discharge.
|R
|Mental Health Tribunal
 
Secretary of State
|}<br />
 
=== Community Treatment Order Recall ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Patient discharged
 
Community Treatment Order revoked
 
Patient died
 
Patient transferred outside England
 
Patient transferred to another Health Care Provider
|}<br />
 
=== Community Treatment Order Recall ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}<br />
 
=== Hospital Provider Spell ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|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.
 
Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments)
 
Court
 
Penal establishment
 
Police Station / Police Custody Suite
 
NHS other Hospital Provider - high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
 
NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department
 
NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
Care Home With Nursing
 
Care Home Without Nursing
 
Local Authority foster care
 
Independent Sector Healthcare Provider run hospital
 
Hospice
 
Not applicable
 
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
|Elective Admission: Waiting list
 
Elective Admission: Booked
 
Elective Admission: Planned
 
Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE
 
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
 
Emergency Admission: Bed bureau
 
Emergency Admission: Consultant Clinic, of this or another Health Care Provider
 
Emergency Admission: Admission via Mental Health Crisis Resolution Team
 
Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted
 
Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency
 
Emergency Admission: Other emergency admission
 
Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency
 
Not applicable
 
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
|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.
 
Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)
 
Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
 
Court
 
Penal establishment
 
Police Station / Police Custody Suite
 
High Security Psychiatric Hospital, Scotland
 
NHS other Hospital Provider - high security psychiatric accommodation
 
NHS other Hospital Provider - medium secure unit
 
NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled
 
NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
Care Home With Nursing
 
Care Home Without Nursing
 
Local Authority foster care
 
PATIENT died or stillbirth
 
Independent Sector Healthcare Provider run hospital - medium secure unit
 
Independent Sector Healthcare Provider run hospital - excluding medium secure unit
 
Hospice
 
ORGANISATION responsible for forced repatriation
 
Not applicable
 
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
|Patient discharged on clinical advice or with clinical consent
 
Patient discharged by mental health review tribunal, Home Secretary or court
 
Patient died
 
Patient discharged him/herself
 
Patient discharged by a relative or advocate
 
Not applicable (Hospital Provider Spell not finished at episode end (i.e. not discharged) or current episode unfinished)
 
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
|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.
 
Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)
 
Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust)
 
Court
 
Penal establishment
 
Police Station / Police Custody Suite
 
High Security Psychiatric Hospital, Scotland
 
NHS other Hospital Provider - high security psychiatric accommodation
 
NHS other Hospital Provider - medium secure unit
 
NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled
 
NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates
 
NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities
 
Care Home With Nursing
 
Care Home Without Nursing
 
Local Authority foster care
 
PATIENT died or stillbirth
 
Independent Sector Healthcare Provider run hospital - medium secure unit
 
Independent Sector Healthcare Provider run hospital - excluding medium secure unit
 
Hospice
 
ORGANISATION responsible for forced repatriation
 
Not applicable
 
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
|Yes - Patient is in scope of transforming care
 
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
|Patient with autism (and no learning disability)
 
Patient with a learning disability (and no autism)
 
Patient with autism and a learning disability
|}<br />
 
=== Ward Stay ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Child and Adolescent Mental Health Ward
 
Paediatric Ward
 
Adult Mental Health Ward
 
Non Mental Health Ward
 
Learning Disabilities Ward
 
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
|Child only
 
Adolescent only
 
Child and Adolescent
 
Adult only
 
Older Adult only
 
Adult and Older Adult
 
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
|Male
 
Female
 
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
|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
 
Mental Illness short stay: Patients intended to stay less than a year
 
Mental Illness long stay: Patients intended to stay a year or more
 
Learning Disability Patients in a designated or interim secure unit
 
Learning Disability Patients intending to stay less than a year
 
Learning Disability Patients intending to stay a year or more
|-
|WARD SECURITY LEVEL
|The level of security for a ward.
|R
|General (non-secure)
 
Low Secure
 
Medium Secure
 
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
|Yes - is a locked WARD
 
No - is not a locked WARD
|-
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
|The classification of the admitted PATIENT during a Ward Stay.
|R
|Acute adult mental health care
 
Acute older adult mental health care (organic and functional)
 
Adult Psychiatric Intensive Care Unit (acute mental health care)
 
Adult Eating Disorders
 
Mother and baby
 
Adult Learning Disabilities
 
Adult High dependency rehabilitation
 
Adult Low secure
 
Adult Medium secure
 
Adult High secure
 
Adult Neuro-psychiatry / Acquired Brain Injury
 
General child and young PERSON admitted PATIENT - Child (including High Dependency)
 
General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency)
 
Eating Disorders admitted patient - Young person (13 years and over)
 
Eating Disorders admitted patient - Child (12 years and under)
 
Child and Young Person Low Secure Mental Illness
 
Child and Young Person Medium Secure Mental Illness
 
Child Mental Health admitted patient services for the Deaf
 
Child and Young Person Learning Disabilities / Autism admitted patient
 
Child and Young Person Low Secure Learning Disabilities
 
Child and Young Person Medium Secure Learning Disabilities
 
Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person
 
Child and Young Person Psychiatric Intensive Care Unit
 
Adult admitted patient continuing care
 
Adult community rehabilitation unit
 
Adult highly specialist high dependency rehabilitation unit
 
Adult longer term high dependency rehabilitation unit
 
Adult mental health admitted patient services for the Deaf
 
Adult personality disorder
|-
|WARD CODE
|A unique identification of a WARD within a Health Care Provider.
|R
|
|}<br />
 
=== Assigned Care Professional ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Respite Care Service
 
Post-COVID-19 Syndrome Service
 
Clinical Psychology Service
 
Learning Disability Service
 
Adult Mental Health Service
 
Child and Adolescent Psychiatry Service
 
Forensic Psychiatry Service
 
Medical Psychotherapy Service
 
Old Age Psychiatry Service
 
Eating Disorders Service
 
Addiction Service
 
Liaison Psychiatry Service
 
Psychiatric Intensive Care Service
 
Perinatal Mental Health Service
 
Mental Health Recovery and Rehabilitation Service
 
Mental Health Dual Diagnosis Service
 
Dementia Assessment Service
 
Neuropsychiatry Service
|}<br />
 
=== Mental Health Delayed Discharge ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Awaiting care coordinator allocation
 
Awaiting public funding
 
Awaiting further non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)
 
Awaiting Care Home Without Nursing placement or availability
 
Awaiting Care Home With Nursing placement or availability
 
Awaiting care package in own home
 
Awaiting community equipment, telecare and/or adaptations
 
Patient or Family choice (reason not stated by patient or family)
 
Patient or Family choice - Non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc)
 
Patient or Family choice - Care Home Without Nursing placement
 
Patient or Family choice - Care Home With Nursing placement
 
Patient or Family choice - Care package in own home
 
Patient or Family choice - Community equipment, telecare and/or adaptations
 
Patient or Family Choice - general needs housing/private landlord acceptance as patient NOT covered by Housing Act/Care Act
 
Patient or Family choice - Supported accommodation
 
Patient or Family choice - Emergency accommodation from the Local Authority under the Housing Act
 
Patient or Family choice - Child or young person awaiting social care or family placement
 
Patient or Family choice - Ministry of Justice agreement/permission of proposed placement
 
Disputes
 
Housing - Awaiting availability of general needs housing/private landlord accommodation acceptance as patient NOT covered by Housing Act and/or Care Act
 
Housing - Single homeless patients or asylum seekers NOT covered by Care Act
 
Housing - Awaiting supported accommodation
 
Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act
 
Child or young person awaiting social care or family placement
 
Awaiting Ministry of Justice agreement/permission of proposed placement
 
Awaiting outcome of legal requirements (mental capacity/mental health legislation)
 
Awaiting residential special school or college placement or availability
 
Lack of local education support
 
Public safety concern unrelated to clinical treatment need (care team)
 
Public safety concern unrelated to clinical treatment need (Ministry of Justice)
 
No lawful community care package available
 
Lack of health care service provision
 
Lack of social care support
 
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
|NHS, excluding housing
 
Social Care, excluding housing
 
Both (NHS and Social Care), excluding housing
 
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
|
|}<br />
 
=== Restrictive Intervention Incident ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
 
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
|Clinical decision to delay
 
Patient refused to take part
 
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
|Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
 
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
|Prevent a patient being violent to others
 
Prevent a patient causing serious intentional harm to themselves
 
Prevent a patient causing serious physical injury to themselves by accident
 
Lawfully administer medicines or other medical treatment
 
Facilitate personal care
 
Facilitate nasogastric (NG) feeding
 
Prevent the patient exhibiting extreme and prolonged over-activity
 
Prevent the PATIENT exhibiting otherwise dangerous behaviour
 
Undertake a search of the patient’s clothing or property to ensure the safety of others
 
Prevent the patient absconding from lawful custody
 
Other (not listed)
 
Not Known (Not Recorded)
|}<br />
 
=== Restrictive Intervention Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Physical restraint - Prone
 
Physical restraint - Standing
 
Physical restraint - Restrictive escort
 
Physical restraint - Supine
 
Physical restraint - Side
 
Physical restraint - Seated
 
Physical restraint - Kneeling
 
Physical restraint - Other (not listed)
 
Chemical restraint - Injection (Rapid Tranquillisation)
 
Chemical restraint - Injection (Non Rapid Tranquillisation)
 
Chemical restraint - Oral
 
Chemical restraint - Other (not listed)
 
Mechanical restraint
 
Seclusion
 
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
|Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
 
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
|Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
 
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
|Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
 
No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|}<br />
 
=== Police Assistance Request ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Yes - the police used restraint or force on a PATIENT
 
No - the police did not use restraint or force on a PATIENT
|}<br />
 
=== Assault ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|DATE OF ASSAULT ON PATIENT
|The DATE that an instance of assault on the PATIENT by another PATIENT occurred.
|M
|
|}<br />
 
=== Self-Harm ===
{| 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 ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}<br />
 
=== Leave Of Absence ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Patient returned on or before day specified
 
Leave revoked and patient recalled by Mental Health Responsible Clinician
 
Period of leave to be extended
 
Patient failed to return on or before day specified and is absent without leave
 
Patient's liability for detention terminated by Mental Health Responsible Clinician
 
Patient's liability for detention terminated by Mental Health Act Review Tribunal
 
Patient's liability for detention terminated by Hospital Managers
 
Patient died
 
Other (not listed)
 
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
|Yes - a period of Mental Health Leave of Absence is escorted
 
No - a period of Mental Health Leave of Absence is not escorted
|}<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)
|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
|
|}<br />
 
=== Hospital Provider Spell Commissioner Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}<br />
 
=== Specialised Mental Health Exceptional Package of Care ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}<br />
 
=== Medical History (Previous Diagnosis) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|DIAGNOSIS SCHEME IN USE (MENTAL HEALTH)
|The code scheme basis of the Diagnosis.
|M
|ICD-10
 
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
|
|}<br />
 
=== Provisional Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
!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 />
 
=== Secondary Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}
<br />
 
=== Coded Scored Assessment (Referral) ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}
<br />
 
=== Care Programme Approach (CPA) Care Episode ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|
|}
<br />
 
=== Care Programme Approach (CPA) Review ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|CARE PROGRAMME APPROACH REVIEW DATE
|The date of the Care Programme Approach review.
|M
|
|}
<br />
 
=== 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
|
|-
|CLUSTERING TOOL ASSESSMENT CATEGORY
|The category of the clustering tool assessment completed.
|M
|Adult Mental Health Clustering Tool
 
Learning Disabilities Clustering Tool
 
Forensic Mental Health Clustering Tool
 
Forensic Learning Disabilities Clustering Tool
 
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
|Initial assessment
 
Scheduled re-assessment
 
Re-assessment following significant unanticipated change in need
 
Other Reason (not listed)
 
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
|Non-Psychotic
 
Psychotic
 
Organic
 
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
|Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
 
Care Cluster 1 - Common Mental Health Problems (Low Severity)
 
Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)
 
Care Cluster 3 - Non-Psychotic (Moderate Severity)
 
Care Cluster 4 - Non-Psychotic (Severe)
 
Care Cluster 5 - Non-Psychotic Disorders (Very Severe)
 
Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas
 
Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)
 
Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders
 
Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.
 
Care Cluster 10 - First Episode Psychosis
 
Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)
 
Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)
 
Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
Care Cluster 14 - Psychotic Crisis
 
Care Cluster 15 - Severe Psychotic Depression
 
Care Cluster 16 - Dual Diagnosis
 
Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)
 
Care Cluster 18 - Cognitive Impairment (Low Need)
 
Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)
 
Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)
 
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
!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
|Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
 
Care Cluster 1 - Common Mental Health Problems (Low Severity)
 
Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)
 
Care Cluster 3 - Non-Psychotic (Moderate Severity)
 
Care Cluster 4 - Non-Psychotic (Severe)
 
Care Cluster 5 - Non-Psychotic Disorders (Very Severe)
 
Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas
 
Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)
 
Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders
 
Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.
 
Care Cluster 10 - First Episode Psychosis
 
Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)
 
Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)
 
Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
Care Cluster 14 - Psychotic Crisis
 
Care Cluster 15 - Severe Psychotic Depression
 
Care Cluster 16 - Dual Diagnosis
 
Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)
 
Care Cluster 18 - Cognitive Impairment (Low Need)
 
Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)
 
Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)
 
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
|Getting Advice: Neurodevelopmental Assessment (NEU)
 
Getting Advice: Signposting and Self-management Advice (ADV)
 
Getting Help: Attention Deficit Hyperactivity Disorder (ADHD)
 
Getting Help: Autism (AUT)
 
Getting Help: Behavioural and/or Conduct Disorders (BEH)
 
Getting Help: Bipolar Disorder (BIP)
 
Getting Help: Depression (DEP)
 
Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP)
 
Getting Help: Obsessive compulsive disorder (OCD)
 
Getting Help: Post-traumatic stress disorder (PTS)
 
Getting Help: Self-harm (SHA)
 
Getting Help: Social Anxiety Disorder (SOC)
 
Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM)
 
Getting Help: Co-occurring Emotional Difficulties (EMO)
 
Getting Help: Difficulties Not Covered by Other Groupings (DNC)
 
Getting More Help: Eating Disorders (EAT)
 
Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP)
 
Getting More Help: Psychosis (PSY)
 
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
|Care Cluster 0: Variance
 
Care Cluster 1: Common Mental Health Problems (Low Severity)
 
Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need)
 
Care Cluster 3: Non-Psychotic (Moderate Severity)
 
Care Cluster 4: Non-Psychotic (Severe)
 
Care Cluster 5: Non-Psychotic Disorders (Very Severe)
 
Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas
 
Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability)
 
Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders
 
Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders
 
Care Cluster 10: First Episode Psychosis
 
Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms)
 
Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability)
 
Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability)
 
Care Cluster 14: Psychotic Crisis
 
Care Cluster 15: Severe Psychotic Depression
 
Care Cluster 16: Dual Diagnosis
 
Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage)
 
Care Cluster 18: Cognitive Impairment (Low Need)
 
Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need)
 
Care Cluster 20: Cognitive Impairment or Dementia (High Need)
 
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
|
|}
<br />
 
=== Five Forensic Pathways ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Initial Assessment
 
Scheduled Re-Assessment
 
Re-Assessment following significant unanticipated change in need
 
Other Reason (not listed)
 
Not Known (Not Recorded)
|-
|FIVE FORENSIC PATHWAYS CODE
|The Five Forensic Pathway assigned to a patient.
|M
|Unable to assign patient to one of the five forensic pathways
 
Treatment responsive group
 
Treatment resistant group – challenging behaviour
 
Treatment resistant group – continuing care
 
Personality disorder group – prison transfer
 
Personality disorder group – co-morbidity
|}
<br />
 
=== Care Professionals ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|PROFESSIONAL REGISTRATION BODY CODE
|A code which identifies the PROFESSIONAL REGISTRATION BODY.
|R
|General Chiropractic Council
 
General Dental Council
 
General Medical Council
 
General Optical Council
 
Social Care Wales
 
Health and Care Professions Council
 
Nursing and Midwifery Council
 
General Pharmaceutical Council
 
General Osteopathic Council
 
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
|Medical
 
Nursing
 
Psychology
 
Primary Mental Health
 
Child and Adolescent Psychotherapy
 
Counselling
 
Family and Systemic Psychotherapy
 
Occupational Therapy
 
Social Work
 
Creative Therapy
 
Other Therapy (Qualified)
 
Education
 
Speech and Language Therapy
 
Other (Qualified)
 
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
|General Medical Practice
 
Learning Disability
 
Adult Mental illness
 
Child and Adolescent Psychiatry
 
Forensic Psychiatry
 
Medical Psychotherapy
 
Old age psychiatry
 
Nursing
 
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
!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
!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
!Value Set
|-
|EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The type of Educational Establishment that the student is attending.
|R
|School
 
College
 
University
 
Other Educational Establishment not listed
 
Not applicable (Patient is not a student)
 
Not stated (Patient asked but declined to provide a response)
 
Not Known (Not Recorded)
|}
 
=== Employment Status ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|SELF EMPLOYED INDICATOR
|'An indication of whether an employed person is self-employed.
|R
|Yes - Employed as a self-employed worker
 
No - Not self employed
 
Not Applicable (Person is unemployed)
 
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
|Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness
 
No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness
 
Not Applicable (The person is unemployed)
 
Not stated (Person asked but declined to provide a response)
 
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
|Yes - the person is currently in receipt of Statutory Sick Pay
 
No - the person is currently not in receipt of Statutory Sick Pay
 
Unknown (Person asked and does not know or is not sure)
 
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
|Yes - the PATIENT is currently in receipt of a benefit
 
No - the PATIENT is not currently in receipt of a benefit
 
Unknown (Person asked and does not know or is not sure)
 
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
|Yes - receiving Employment and Support Allowance
 
No - not receiving Employment and Support Allowance
 
Unknown (Patient asked and does not know or is not sure)
 
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
|Yes - receiving Universal Credit
 
No - not receiving Universal Credit
 
Unknown (Patient asked and does not know or is not sure)
 
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
|Yes - receiving Personal Independence Payment
 
No - Not receiving Personal Independence Payment
 
Unknown (Patient asked and does not know or is not sure)
 
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
|Yes - the patient is a suitable candidate for referral to Employment Support
 
No - the patient is not a suitable candidate for referral to Employment Support
 
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
!Value Set
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE
|
|R
|
|}<br />
=== Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES
|The source of referral to a Mental Health Service.
|R
|Primary Health Care: General Medical Practitioner Practice
 
Primary Health Care: Health Visitor
 
Other Primary Health Care
 
Primary Health Care: Maternity Service
 
Self Referral: Self
 
Self Referral: Carer/Relative
 
Local Authority and Other Public Services: Social Services
 
Local Authority and Other Public Services: Education Service / Educational Establishment
 
Local Authority and Other Public Services: Housing Service
 
Employer
 
Employer: Occupational Health
 
Justice System: Police
 
Justice System: Courts
 
Justice System: Probation Service
 
Justice System: Prison
 
Justice System: Court Liaison and Diversion Service
 
Justice System: Youth Offending Team
 
Child Health: School Nurse
 
Child Health: Hospital-based Paediatrics
 
Child Health: Community-based Paediatrics
 
Independent sector - Medium Secure Inpatients
 
Independent Sector - Low Secure Inpatients
 
Other Independent Sector Mental Health Services
 
Voluntary Sector
 
Acute Secondary Care: Emergency Care Department
 
Other secondary care specialty
 
Temporary transfer from another Mental Health NHS Trust
 
Permanent transfer from another Mental Health NHS Trust
 
Other: Asylum Services
 
Other: Telephone or Electronic Access Service
 
Other: Out of Area Agency
 
Other: Drug Action Team / Drug Misuse Agency
 
Other: Jobcentre Plus
 
Other SERVICE or agency
 
Other: Single Point of Access Service
 
Debt agency
 
Stepped up from low intensity Improving Access to Psychological Therapies Service
 
Stepped down from high intensity Improving Access to Psychological Therapies Service
 
Other Improving Access to Psychological Therapies Service
 
Internal Referral
 
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
|Yes - this is a recurrence of a previously diagnosed condition
 
No - this is not a recurrence of a previously diagnosed condition
 
Unknown (Patient asked and does not know or is unsure)
 
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'''
 
Not assessed
 
 
'''Seen but not taken on for a course of treatment'''
 
Not suitable for IAPT service - no action taken or directed back to referrer
 
Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient
 
Discharged by mutual agreement following advice and support
 
Referred to another therapy service by mutual agreement
 
Suitable for IAPT service, but patient declined treatment that was offered
 
Incomplete Assessment (Patient dropped out)
 
Deceased (Seen but not taken on for a course of treatment)
 
Not Known (Seen but not taken on for a course of treatment)
 
 
'''Seen and taken on for a course of treatment'''
 
Mutually agreed completion of treatment
 
Termination of treatment earlier than Care Professional planned
 
Termination of treatment earlier than patient requested
 
Deceased (Seen and taken on for a course of treatment)
 
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
!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
|Transfer of Clinical Responsibility
 
For Opinion Only
 
For Diagnostic Test Only
 
New Referral (Non Transfer)
 
Stepped up from low intensity Improving Access to Psychological Therapies Service
 
Stepped down from high intensity Improving Access to Psychological Therapies Service
 
Other (not listed)
 
Onward Referral Reason Not Applicable
 
Not Known (Not Recorded)
|}
 
=== 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
|
|-
|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
|Patient unavailable due to holiday
 
Patient unavailable due to other health needs
 
Patient stated not available - other reason (not listed)
|}
 
=== Care Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Yes - Appointment slot could be reallocated
 
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
|Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological
 
Therapies Long Term Condition Service
 
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
|Assessment
 
Treatment
 
Assessment and treatment
 
Review only
 
Review and treatment
 
Follow-up appointment after treatment end
 
Employment Support
 
Other (not listed)
 
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
|Prescribed but not taking
 
Prescribed and taking
 
Not Prescribed
 
Unknown (Patient asked and does not know or is not sure)
 
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'''
 
Braille (for people who are unable to see)
 
American Sign Language
 
Australian Sign Language
 
British Sign Language
 
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
|Yes - Professional interpreter
 
Yes - Family member or friend
 
Yes - Another Person
 
No - Interpreter not required
 
No - Interpreter was required but did not attend
 
Not Known (Not Recorded)
|}
 
=== Internet Therapy Log ===
{| class="wikitable"
!Name
!Description
!Conformance
!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
|Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy
 
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
!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
!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
!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
|Primary Presenting Complaint
 
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
!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
!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
|Curriculum for Psychological Wellbeing Practitioners (PWP)
 
Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT)
 
Curriculum for Counselling for Depression (CfD)
 
Curriculum for Couple Therapy for Depression
 
(CTfD) / Curriculum for Behavioural Couples
 
Therapy (BCT) for Depression
 
Curriculum for Dynamic
 
Interpersonal Therapy (DIT) for Depression
 
Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT)
 
Curriculum for Mindfulness-based Cognitive Therapy (MBCT)
 
Curriculum for Eye Movement Desensitisation Reprocessing (EMDR)
 
Curriculum for Employment Advisers
 
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 ===
{| class="wikitable"
!Name
!Description
!Conformance
!Value Set
|-
|FREEFORM NOTES
|Any related notes deemed useful for inclusion within the DDS
|R
|R
|
|
|-
|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
|
|
|-
|WARD SECURITY LEVEL
|The level of security for a ward.
|R
|
|
|-
|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
|
|
|-
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
|The classification of the admitted PATIENT during a Ward Stay.
|R
|
|
|-
|WARD CODE
|A unique identification of a WARD within a Health Care Provider.
|R
|
|
|
|}
|}
__FORCETOC__
__FORCETOC__

Revision as of 17:43, 2 February 2023

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.

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


Master Patient Index

Name Description Conformance 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 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 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 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 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 Yes - PATIENT requires constant care and/or supervision

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 Yes - PATIENT has parental responsibilities for a child or young person

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

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

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 Yes - PATIENT has a caring role for an ill or disabled parent, Carer or sibling

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

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

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 Section 20 Voluntary Agreement

Section 31 Care Order

Section 38 Interim Care Order

Other (not listed)

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

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 Has never been subject to a Child Protection Plan

Has previously been subject to a Child Protection Plan

Is currently subject to a Child Protection Plan

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 Ex-services member

Not an ex-services member or their dependant

Dependant of an ex-services member

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

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 No - No offence

Yes - Less serious offence

Yes - Serious offence

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 Yes - the patient requires a Reasonable Adjustment

No - the patient does not require a Reasonable Adjustment


Mental Health Care Coordinator

Name Description Conformance 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 Day Care Service

Crisis Resolution Team/Home Treatment Service

Primary Care Mental Health Service

Community Mental Health Team - Functional

Community Mental Health Team - Organic

Assertive Outreach Team

Community Rehabilitation Service

General Psychiatry Service

Psychiatric Liaison Service

Psychotherapy Service

Psychological Therapy Service (non IAPT)

Early Intervention Team for Psychosis

Young Onset Dementia Team

Personality Disorder Service

Memory Services/Clinic/Drop in service

Single Point of Access Service

24/7 Crisis Response Line

Health Based Place Of Safety Service

Crisis Café/Safe Haven/Sanctuary Service

Walk-in Crisis Assessment Unit Service

Psychiatric Decision Unit Service

Acute Day Service

Crisis House Service

Forensic Mental Health Service

Forensic Learning Disability Service

Autism Service

Specialist Perinatal Mental Health Community Service

Neurodevelopment Team

Paediatric Liaison Service

Looked After Children Service

Youth Offending Service

Acquired Brain Injury Service

Community Eating Disorder Service

Substance Misuse Team

Criminal Justice Liaison and Diversion Service

Prison Psychiatric Inreach Service

Asylum Service

Individual Placement and Support Service

Mental Health In Education Service

Problem Gambling Service

Rough Sleeping Service

Community Team for Learning Disabilities

Epilepsy/Neurological Service

Specialist Parenting Service

Enhanced/Intensive Support Service

Mental Health Support Team

Maternal Mental Health Service

Mental Health Services for Deaf people

Veterans Complex Treatment Service

Enhanced care in care homes teams

Mental Health and Wellbeing Hubs

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

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


DisabilityType

Name Description Conformance 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 Behaviour and Emotional

Hearing

Manual Dexterity

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

Mobility and Gross Motor

Perception of Physical Danger

Personal, Self Care and Continence

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

Sight

Speech

Other (not listed)

No Disability

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 Yes – limited a lot

Yes – limited a little

No - not limited

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


Care Plan Type

Name Description Conformance 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 Mental Health Care Plan

Urgent and Emergency Mental Health Care Plan

Mental Health Crisis Plan

Positive Behaviour Support Plan

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

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

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 At the request of the patient

Access restrictions on the family

No known family

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
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 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 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 Value Set
OVERSEAS VISITOR CHARGING CATEGORY The charging category relating to an OVERSEAS VISITOR STATUS. M Standard NHS-funded PATIENT

Immigration Health Surcharge payee

Charge-exempt Overseas Visitor (European Economic Area)

Chargeable European Economic Area PATIENT

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

Chargeable non-European Economic Area PATIENT

Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY

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 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 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 Primary Health Care: General Medical Practitioner Practice

Primary Health Care: Health Visitor

Other Primary Health Care

Primary Health Care: Maternity Service

Self-Referral: Self

Self-Referral: Carer/Relative

Local Authority and Other Public Services: Social Services

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

Local Authority and Other Public Services: Housing Service

Employer

Employer: Occupational Health

Justice System: Police

Justice System: Courts

Justice System: Probation Service

Justice System: Prison

Justice System: Court Liaison and Diversion Service

Justice System: Youth Offending Team

Child Health: School Nurse

Child Health: Hospital-based Paediatrics

Child Health: Community-based Paediatrics

Independent sector - Medium Secure Inpatients

Independent Sector - Low Secure Inpatients

Other Independent Sector Mental Health Services

Voluntary Sector

Acute Secondary Care: Emergency Care Department

Other secondary care specialty

Temporary transfer from another Mental Health NHS Trust

Permanent transfer from another Mental Health NHS Trust

Other: Asylum Services

Other: Telephone or Electronic Access Service

Other: Out of Area Agency

Other: Drug Action Team / Drug Misuse Agency

Other: Jobcentre Plus

Other SERVICE or agency

Other: Single Point of Access Service

Other: Urgent and Emergency Care Ambulance Service

Improving Access to Psychological Therapies Service

Internal Referral

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 Art Therapist

Clinical Psychologist

Dietitian

Dramatherapist

Music Therapist

Occupational Therapist

Orthotist

Physiotherapist

Podiatrist

Prosthetist

Psychotherapist

Radiographer

Speech and Language Therapist

Orthoptist

Community Dentist

Consultant

General Medical Practitioner

General Practitioner with an Extended Role (GPwER)

Midwife

District Nurse

Health Visitor

Macmillan Nurse

School Nurse

Specialist Nursing - Active Case Management (Community Matrons)

Specialist Nursing - Arthritis Nursing/Liaison

Specialist Nursing - Asthma and Respiratory Nursing/Liaison

Specialist Nursing - Breast Care Nursing/Liaison

Specialist Nursing - Cancer Related

Specialist Nursing - Cardiac Nursing/Liaison

Specialist Nursing - Children's Services

Specialist Nursing - Community Cystic Fibrosis

Specialist Nursing - Continence Services

Specialist Nursing - Diabetic Nursing/Liaison

Specialist Nursing - Enteral Feeding Nursing Services

Specialist Nursing - Haemophilia Nursing Services

Specialist Nursing - Infectious Diseases

Specialist Nursing - Intensive Care Nursing

Specialist Nursing - Palliative/Respite Care

Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison

Specialist Nursing - Rehabilitation Nursing

Specialist Nursing - Stoma Care Services

Specialist Nursing - Tissue Viability Nursing/Liaison

Specialist Nursing - Transplantation Patients Nursing Services

Specialist Nursing - Treatment Room Nursing Services

Specialist Nursing - Tuberculosis Specialist Nursing

Specialist Nursing - Other Specialist Nursing

Specialist Nursing - Safeguarding

Practice Nursing

Staff Nurse

Other Registered Nurse

Public Health Nurse

Appliances Technician

Audiologist

Counsellor

Nursery Nurse

Play Therapist

Social Worker

Voluntary Care Worker

Screener (in a National Screening Programme)

Other Care Professional (not listed)

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

Urgent/Serious

Routine

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 (Suspected) First Episode Psychosis

Ongoing or Recurrent Psychosis

Bi polar disorder

Depression

Anxiety

Obsessive compulsive disorder

Phobias

Organic brain disorder

Drug and alcohol difficulties

Unexplained physical symptoms

Post-traumatic stress disorder

Eating disorders

Perinatal mental health issues

Personality disorders

Self harm behaviours

Conduct disorders

In crisis

Relationship difficulties

Gender Discomfort issues

Attachment difficulties

Self - care issues

Adjustment to health issues

Neurodevelopmental Conditions, excluding Autism

Suspected Autism

Diagnosed Autism

Preconception perinatal mental health concern

Gambling disorder

Community Perinatal Mental Health Partner Assessment

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 Unavailability of bed at referring organisation

Safeguarding

Offending restrictions

Staff member or family/friend within the referring organisation

Patient choice

Patient away from home

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 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 (Suspected) First Episode Psychosis

Ongoing or Recurrent Psychosis

Bi polar disorder

Depression

Anxiety

Obsessive compulsive disorder

Phobias

Organic brain disorder

Drug and alcohol difficulties

Unexplained physical symptoms

Post-traumatic stress disorder

Eating disorders

Perinatal mental health issues

Personality disorders

Self harm behaviours

Conduct disorders

In crisis

Relationship difficulties

Gender Discomfort issues

Attachment difficulties

Self - care issues

Adjustment to health issues

Neurodevelopmental Conditions, excluding Autism

Suspected Autism

Diagnosed Autism

Preconception perinatal mental health concern

Gambling disorder

Community Perinatal Mental Health Partner Assessment

Behaviours that challenge due to a Learning Disability


Service or Team Type Referred To

Name Description Conformance 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 Day Care Service

Crisis Resolution Team/Home Treatment Service

Primary Care Mental Health Service

Community Mental Health Team - Functional

Community Mental Health Team - Organic

Assertive Outreach Team

Community Rehabilitation Service

General Psychiatry Service

Psychiatric Liaison Service

Psychotherapy Service

Psychological Therapy Service (non IAPT)

Early Intervention Team for Psychosis

Young Onset Dementia Team

Personality Disorder Service

Memory Services/Clinic/Drop in service

Single Point of Access Service

24/7 Crisis Response Line

Health Based Place Of Safety Service

Crisis Café/Safe Haven/Sanctuary Service

Walk-in Crisis Assessment Unit Service

Psychiatric Decision Unit Service

Acute Day Service

Crisis House Service

Forensic Mental Health Service

Forensic Learning Disability Service

Autism Service

Specialist Perinatal Mental Health Community Service

Neurodevelopment Team

Paediatric Liaison Service

Looked After Children Service

Youth Offending Service

Acquired Brain Injury Service

Community Eating Disorder Service

Substance Misuse Team

Criminal Justice Liaison and Diversion Service

Prison Psychiatric Inreach Service

Asylum Service

Individual Placement and Support Service

Mental Health In Education Service

Problem Gambling Service

Rough Sleeping Service

Community Team for Learning Disabilities

Epilepsy/Neurological Service

Specialist Parenting Service

Enhanced/Intensive Support Service

Mental Health Support Team

Maternal Mental Health Service

Mental Health Services for Deaf people

Veterans Complex Treatment Service

Enhanced care in care homes teams

Mental Health and Wellbeing Hubs

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

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 Admitted elsewhere (at the same or other Health Care Provider)

Treatment completed

Moved out of the area

No further treatment appropriate

Patient did not attend

Patient died

Patient requested discharge

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

PATIENT refused to be seen

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

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

Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST)


Referral to Treatment (RTT)

Name 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 Allied Health Professional Referral To Treatment Measurement

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 First activity in a Referral to Treatment Period

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

Referral to Treatment Period status not yet known


Onward Referral

Name Description Conformance 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 Transfer of Clinical Responsibility

For Opinion Only

For Diagnostic Test Only

New Referral (Non Transfer)

Other (not listed)

Onward Referral Reason Not Applicable

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 Unavailability of bed at referring organisation

Safeguarding

Offending restrictions

Staff member or family/friend within the referring organisation

Patient choice

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 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 Patient or Patient Proxy

Advocate

Clinical Service or Team

Local Community Support Team

Current Commissioner

Commissioner of Planned Discharge Destination

Family member or carer with parental responsibility

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 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 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 NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)

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

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

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.

Not applicable

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 Initial Consultation

Follow-up Consultation

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

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 Face to face

Telephone

Talk type for a person unable to speak

Email

Text Message (Asynchronous)

Instant messaging (Synchronous)

Video consultation

Message Board (Asynchronous)

Chat Room (Synchronous)

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 Patient's home

Carer's home

Patient's workplace

Other patient related location

Primary Care Health Centre

Polyclinic

General Medical Practitioner Practice

Dental Practice

Ophthalmic Medical Practitioner premises

Walk In Centre

Out of Hours Centre

Emergency Community Dental Service

Out-Patient Clinic

Ward

Day Hospital

Emergency Care Department or Minor Injuries Department

Other departments

Hospice

Care Home Without Nursing

Care Home With Nursing

Children’s Home

Integrated Care Home Without Nursing and Care Home With Nursing

Day Centre

Resource Centre

Sure Start Children’s Centre

Child Development Centre

School

Further Education College

University

Nursery Premises

Other Childcare Premises

Training Establishments

Other Educational Premises

Prison

Probation Service Premises

Police Station / Police Custody Suite

Young Offender Institution

Young Offender Institution (15-17)

Young Offender Institution (18-21)

Immigration Removal Centre

Street or other public open space

Other publicly accessible area or building

Voluntary or charitable agency premises

Dispensing Optician premises

Dispensing Pharmacy premises

Other locations not elsewhere classified

General Health Promotion Session

Telephone Support Sessiom

Thereputic Group Session

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

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 Yes - a Community Perinatal Mental Health Partner Assessment has been offered

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 Yes - the care contact is a result of a planned Appointment

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 Individual patient

Couple

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 Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT

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

Patient arrived late and could not be seen

APPOINTMENT cancelled by, or on behalf of, the PATIENT

Did not attend - no advance warning given

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 Cancelled for Clinical Reasons

Cancelled for Non-clinical Reasons

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

No - a Reasonable Adjustment was not made for the patient

Not applicable


Care Activity

Name Description Conformance 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 ICD-10

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 Value Set
OTHER PERSON IN ATTENDANCE AT CARE CONTACT The other PERSON in attendance, with the PATIENT, at the CARE CONTACT. M Independent Advocate (Family Member)

Independent Advocate (Independent Person)

Independent Mental Capacity Advocate (IMCA)

Independent Mental Health Advocate (IMHA)

Non-Instructed Advocate

Parent or relative (Non-Advocate)

Friend or neighbour (Non-Advocate)

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 PATIENT has chosen not to have an Independent Mental Health Advocate

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

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

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

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

Other (not listed)

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 Patient has chosen not to have an Independent Mental Health Advocate

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

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

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

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

Other (not listed)

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


Indirect Activity

Name Description Conformance 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 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 General Health Promotion Session

Telephone Support Session

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 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 Memory Services/Clinic/Drop In Service

24/7 Crisis Response Line

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 Act Legal Status Classification Assignment Period

Name Description Conformance 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 Change in Mental Health Act Legal Status Classification Code (including from informal)

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 Change in Mental Health Act Legal Status Classification Code (including to informal)

Transfer to other Health Care Provider

Death of patient

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

Formally detained under Mental Health Act Section 2

Formally detained under Mental Health Act Section 3

Formally detained under Mental Health Act Section 4

Formally detained under Mental Health Act Section 5 (2)

Formally detained under Mental Health Act Section 5 (4)

Formally detained under Mental Health Act Section 35

Formally detained under Mental Health Act Section 36

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

Formally detained under Mental Health Act Section 37

Formally detained under Mental Health Act Section 38

Formally detained under Mental Health Act Section 44

Formally detained under Mental Health Act Section 46

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

Formally detained under Mental Health Act Section 47

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

Formally detained under Mental Health Act Section 48

Formally detained under Mental Health Act Section 135

Formally detained under Mental Health Act Section 136

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

Formally detained under other acts

Subject to guardianship under Mental Health Act Section 7

Subject to guardianship under Mental Health Act Section 37

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

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

Not Applicable

Not Known

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

Mental disorder (Learning Disability primary reason for using Act)

Not applicable (i.e. not detained)

Not Known (Not Recorded)


Mental Health Responsible Clinician Assignment Period

Name Description Conformance 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 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 Mental Health absolute discharge

Recall of PATIENT

Death of PATIENT

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

Secretary of State


Community Treatment Order Recall

Name Description Conformance 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 Patient discharged

Community Treatment Order revoked

Patient died

Patient transferred outside England

Patient transferred to another Health Care Provider


Community Treatment Order Recall

Name Description Conformance 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 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 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.

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

Court

Penal establishment

Police Station / Police Custody Suite

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

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

NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

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

Care Home With Nursing

Care Home Without Nursing

Local Authority foster care

Independent Sector Healthcare Provider run hospital

Hospice

Not applicable

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 Elective Admission: Waiting list

Elective Admission: Booked

Elective Admission: Planned

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

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

Emergency Admission: Bed bureau

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

Emergency Admission: Admission via Mental Health Crisis Resolution Team

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

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

Emergency Admission: Other emergency admission

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

Not applicable

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 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.

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

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

Court

Penal establishment

Police Station / Police Custody Suite

High Security Psychiatric Hospital, Scotland

NHS other Hospital Provider - high security psychiatric accommodation

NHS other Hospital Provider - medium secure unit

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

NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

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

Care Home With Nursing

Care Home Without Nursing

Local Authority foster care

PATIENT died or stillbirth

Independent Sector Healthcare Provider run hospital - medium secure unit

Independent Sector Healthcare Provider run hospital - excluding medium secure unit

Hospice

ORGANISATION responsible for forced repatriation

Not applicable

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 Patient discharged on clinical advice or with clinical consent

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

Patient died

Patient discharged him/herself

Patient discharged by a relative or advocate

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

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 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.

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

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

Court

Penal establishment

Police Station / Police Custody Suite

High Security Psychiatric Hospital, Scotland

NHS other Hospital Provider - high security psychiatric accommodation

NHS other Hospital Provider - medium secure unit

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

NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

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

Care Home With Nursing

Care Home Without Nursing

Local Authority foster care

PATIENT died or stillbirth

Independent Sector Healthcare Provider run hospital - medium secure unit

Independent Sector Healthcare Provider run hospital - excluding medium secure unit

Hospice

ORGANISATION responsible for forced repatriation

Not applicable

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 Yes - Patient is in scope of transforming care

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 Patient with autism (and no learning disability)

Patient with a learning disability (and no autism)

Patient with autism and a learning disability


Ward Stay

Name Description Conformance 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 Child and Adolescent Mental Health Ward

Paediatric Ward

Adult Mental Health Ward

Non Mental Health Ward

Learning Disabilities Ward

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 Child only

Adolescent only

Child and Adolescent

Adult only

Older Adult only

Adult and Older Adult

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 Male

Female

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 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

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

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

Learning Disability Patients in a designated or interim secure unit

Learning Disability Patients intending to stay less than a year

Learning Disability Patients intending to stay a year or more

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

Low Secure

Medium Secure

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 Yes - is a locked WARD

No - is not a locked WARD

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

Acute older adult mental health care (organic and functional)

Adult Psychiatric Intensive Care Unit (acute mental health care)

Adult Eating Disorders

Mother and baby

Adult Learning Disabilities

Adult High dependency rehabilitation

Adult Low secure

Adult Medium secure

Adult High secure

Adult Neuro-psychiatry / Acquired Brain Injury

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

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

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

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

Child and Young Person Low Secure Mental Illness

Child and Young Person Medium Secure Mental Illness

Child Mental Health admitted patient services for the Deaf

Child and Young Person Learning Disabilities / Autism admitted patient

Child and Young Person Low Secure Learning Disabilities

Child and Young Person Medium Secure Learning Disabilities

Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person

Child and Young Person Psychiatric Intensive Care Unit

Adult admitted patient continuing care

Adult community rehabilitation unit

Adult highly specialist high dependency rehabilitation unit

Adult longer term high dependency rehabilitation unit

Adult mental health admitted patient services for the Deaf

Adult personality disorder

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


Assigned Care Professional

Name Description Conformance 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 Respite Care Service

Post-COVID-19 Syndrome Service

Clinical Psychology Service

Learning Disability Service

Adult Mental Health Service

Child and Adolescent Psychiatry Service

Forensic Psychiatry Service

Medical Psychotherapy Service

Old Age Psychiatry Service

Eating Disorders Service

Addiction Service

Liaison Psychiatry Service

Psychiatric Intensive Care Service

Perinatal Mental Health Service

Mental Health Recovery and Rehabilitation Service

Mental Health Dual Diagnosis Service

Dementia Assessment Service

Neuropsychiatry Service


Mental Health Delayed Discharge

Name Description Conformance 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 Awaiting care coordinator allocation

Awaiting public funding

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

Awaiting Care Home Without Nursing placement or availability

Awaiting Care Home With Nursing placement or availability

Awaiting care package in own home

Awaiting community equipment, telecare and/or adaptations

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

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

Patient or Family choice - Care Home Without Nursing placement

Patient or Family choice - Care Home With Nursing placement

Patient or Family choice - Care package in own home

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

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

Patient or Family choice - Supported accommodation

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

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

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

Disputes

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

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

Housing - Awaiting supported accommodation

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

Child or young person awaiting social care or family placement

Awaiting Ministry of Justice agreement/permission of proposed placement

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

Awaiting residential special school or college placement or availability

Lack of local education support

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

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

No lawful community care package available

Lack of health care service provision

Lack of social care support

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 NHS, excluding housing

Social Care, excluding housing

Both (NHS and Social Care), excluding housing

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 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 Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

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 Clinical decision to delay

Patient refused to take part

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 Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

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 Prevent a patient being violent to others

Prevent a patient causing serious intentional harm to themselves

Prevent a patient causing serious physical injury to themselves by accident

Lawfully administer medicines or other medical treatment

Facilitate personal care

Facilitate nasogastric (NG) feeding

Prevent the patient exhibiting extreme and prolonged over-activity

Prevent the PATIENT exhibiting otherwise dangerous behaviour

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

Prevent the patient absconding from lawful custody

Other (not listed)

Not Known (Not Recorded)


Restrictive Intervention Type

Name Description Conformance 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 Physical restraint - Prone

Physical restraint - Standing

Physical restraint - Restrictive escort

Physical restraint - Supine

Physical restraint - Side

Physical restraint - Seated

Physical restraint - Kneeling

Physical restraint - Other (not listed)

Chemical restraint - Injection (Rapid Tranquillisation)

Chemical restraint - Injection (Non Rapid Tranquillisation)

Chemical restraint - Oral

Chemical restraint - Other (not listed)

Mechanical restraint

Seclusion

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 Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

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 Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

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 Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

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


Police Assistance Request

Name Description Conformance 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 Yes - the police used restraint or force on a PATIENT

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


Assault

Name Description Conformance 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 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 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 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 Patient returned on or before day specified

Leave revoked and patient recalled by Mental Health Responsible Clinician

Period of leave to be extended

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

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

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

Patient's liability for detention terminated by Hospital Managers

Patient died

Other (not listed)

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 Yes - a period of Mental Health Leave of Absence is escorted

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


Mental Health Trial Leave

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) 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 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 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 Value Set
DIAGNOSIS SCHEME IN USE (MENTAL HEALTH) The code scheme basis of the Diagnosis. M ICD-10

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 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 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 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 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 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 Value Set
CARE PROGRAMME APPROACH REVIEW DATE The date of the Care Programme Approach review. M


Clustering Tool Assessment

Name Description Conformance 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 Adult Mental Health Clustering Tool

Learning Disabilities Clustering Tool

Forensic Mental Health Clustering Tool

Forensic Learning Disabilities Clustering Tool

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 Initial assessment

Scheduled re-assessment

Re-assessment following significant unanticipated change in need

Other Reason (not listed)

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 Non-Psychotic

Psychotic

Organic

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 Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

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

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

Care Cluster 3 - Non-Psychotic (Moderate Severity)

Care Cluster 4 - Non-Psychotic (Severe)

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

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

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

Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

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

Care Cluster 10 - First Episode Psychosis

Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

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

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

Care Cluster 14 - Psychotic Crisis

Care Cluster 15 - Severe Psychotic Depression

Care Cluster 16 - Dual Diagnosis

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

Care Cluster 18 - Cognitive Impairment (Low Need)

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

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

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 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 Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

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

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

Care Cluster 3 - Non-Psychotic (Moderate Severity)

Care Cluster 4 - Non-Psychotic (Severe)

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

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

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

Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

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

Care Cluster 10 - First Episode Psychosis

Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

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

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

Care Cluster 14 - Psychotic Crisis

Care Cluster 15 - Severe Psychotic Depression

Care Cluster 16 - Dual Diagnosis

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

Care Cluster 18 - Cognitive Impairment (Low Need)

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

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

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 Getting Advice: Neurodevelopmental Assessment (NEU)

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

Getting Help: Attention Deficit Hyperactivity Disorder (ADHD)

Getting Help: Autism (AUT)

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

Getting Help: Bipolar Disorder (BIP)

Getting Help: Depression (DEP)

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

Getting Help: Obsessive compulsive disorder (OCD)

Getting Help: Post-traumatic stress disorder (PTS)

Getting Help: Self-harm (SHA)

Getting Help: Social Anxiety Disorder (SOC)

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

Getting Help: Co-occurring Emotional Difficulties (EMO)

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

Getting More Help: Eating Disorders (EAT)

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

Getting More Help: Psychosis (PSY)

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 Care Cluster 0: Variance

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

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

Care Cluster 3: Non-Psychotic (Moderate Severity)

Care Cluster 4: Non-Psychotic (Severe)

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

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

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

Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders

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

Care Cluster 10: First Episode Psychosis

Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms)

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

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

Care Cluster 14: Psychotic Crisis

Care Cluster 15: Severe Psychotic Depression

Care Cluster 16: Dual Diagnosis

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

Care Cluster 18: Cognitive Impairment (Low Need)

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

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

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 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 Initial Assessment

Scheduled Re-Assessment

Re-Assessment following significant unanticipated change in need

Other Reason (not listed)

Not Known (Not Recorded)

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

Treatment responsive group

Treatment resistant group – challenging behaviour

Treatment resistant group – continuing care

Personality disorder group – prison transfer

Personality disorder group – co-morbidity


Care Professionals

Name Description Conformance Value Set
PROFESSIONAL REGISTRATION BODY CODE A code which identifies the PROFESSIONAL REGISTRATION BODY. R General Chiropractic Council

General Dental Council

General Medical Council

General Optical Council

Social Care Wales

Health and Care Professions Council

Nursing and Midwifery Council

General Pharmaceutical Council

General Osteopathic Council

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 Medical

Nursing

Psychology

Primary Mental Health

Child and Adolescent Psychotherapy

Counselling

Family and Systemic Psychotherapy

Occupational Therapy

Social Work

Creative Therapy

Other Therapy (Qualified)

Education

Speech and Language Therapy

Other (Qualified)

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 General Medical Practice

Learning Disability

Adult Mental illness

Child and Adolescent Psychiatry

Forensic Psychiatry

Medical Psychotherapy

Old age psychiatry

Nursing

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 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 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 Value Set
EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) The type of Educational Establishment that the student is attending. R School

College

University

Other Educational Establishment not listed

Not applicable (Patient is not a student)

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

Not Known (Not Recorded)

Employment Status

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

No - Not self employed

Not Applicable (Person is unemployed)

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 Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness

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

Not Applicable (The person is unemployed)

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

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 Yes - the person is currently in receipt of Statutory Sick Pay

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

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

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 Yes - the PATIENT is currently in receipt of a benefit

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

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

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 Yes - receiving Employment and Support Allowance

No - not receiving Employment and Support Allowance

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

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 Yes - receiving Universal Credit

No - not receiving Universal Credit

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

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 Yes - receiving Personal Independence Payment

No - Not receiving Personal Independence Payment

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

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 Yes - the patient is a suitable candidate for referral to Employment Support

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

Not Applicable

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


Social & Personal Circumstances

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


Referral

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

Primary Health Care: Health Visitor

Other Primary Health Care

Primary Health Care: Maternity Service

Self Referral: Self

Self Referral: Carer/Relative

Local Authority and Other Public Services: Social Services

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

Local Authority and Other Public Services: Housing Service

Employer

Employer: Occupational Health

Justice System: Police

Justice System: Courts

Justice System: Probation Service

Justice System: Prison

Justice System: Court Liaison and Diversion Service

Justice System: Youth Offending Team

Child Health: School Nurse

Child Health: Hospital-based Paediatrics

Child Health: Community-based Paediatrics

Independent sector - Medium Secure Inpatients

Independent Sector - Low Secure Inpatients

Other Independent Sector Mental Health Services

Voluntary Sector

Acute Secondary Care: Emergency Care Department

Other secondary care specialty

Temporary transfer from another Mental Health NHS Trust

Permanent transfer from another Mental Health NHS Trust

Other: Asylum Services

Other: Telephone or Electronic Access Service

Other: Out of Area Agency

Other: Drug Action Team / Drug Misuse Agency

Other: Jobcentre Plus

Other SERVICE or agency

Other: Single Point of Access Service

Debt agency

Stepped up from low intensity Improving Access to Psychological Therapies Service

Stepped down from high intensity Improving Access to Psychological Therapies Service

Other Improving Access to Psychological Therapies Service

Internal Referral

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 Yes - this is a recurrence of a previously diagnosed condition

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

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

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

Not assessed


Seen but not taken on for a course of treatment

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

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

Discharged by mutual agreement following advice and support

Referred to another therapy service by mutual agreement

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

Incomplete Assessment (Patient dropped out)

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

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


Seen and taken on for a course of treatment

Mutually agreed completion of treatment

Termination of treatment earlier than Care Professional planned

Termination of treatment earlier than patient requested

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

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 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 Transfer of Clinical Responsibility

For Opinion Only

For Diagnostic Test Only

New Referral (Non Transfer)

Stepped up from low intensity Improving Access to Psychological Therapies Service

Stepped down from high intensity Improving Access to Psychological Therapies Service

Other (not listed)

Onward Referral Reason Not Applicable

Not Known (Not Recorded)

Waiting Time Pauses

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
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 Patient unavailable due to holiday

Patient unavailable due to other health needs

Patient stated not available - other reason (not listed)

Care Contact

Name Description Conformance 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 Yes - Appointment slot could be reallocated

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 Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological

Therapies Long Term Condition Service

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 Assessment

Treatment

Assessment and treatment

Review only

Review and treatment

Follow-up appointment after treatment end

Employment Support

Other (not listed)

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 Prescribed but not taking

Prescribed and taking

Not Prescribed

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

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

Braille (for people who are unable to see)

American Sign Language

Australian Sign Language

British Sign Language

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 Yes - Professional interpreter

Yes - Family member or friend

Yes - Another Person

No - Interpreter not required

No - Interpreter was required but did not attend

Not Known (Not Recorded)

Internet Therapy Log

Name Description Conformance 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 Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy

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

Medical History Previous Diagnosis

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

Long Term Condition

Name Description Conformance 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 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 Primary Presenting Complaint

Secondary Presenting Complaint

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

Care Cluster

Name Description Conformance 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 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 Curriculum for Psychological Wellbeing Practitioners (PWP)

Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT)

Curriculum for Counselling for Depression (CfD)

Curriculum for Couple Therapy for Depression

(CTfD) / Curriculum for Behavioural Couples

Therapy (BCT) for Depression

Curriculum for Dynamic

Interpersonal Therapy (DIT) for Depression

Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT)

Curriculum for Mindfulness-based Cognitive Therapy (MBCT)

Curriculum for Eye Movement Desensitisation Reprocessing (EMDR)

Curriculum for Employment Advisers

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 Value Set
FREEFORM NOTES Any related notes deemed useful for inclusion within the DDS R