Mental Health FHIR Store Mappings: Difference between revisions
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=== Patient | == MHSDS == | ||
<br /><ol> | |||
<!-- subsection items --> </ol> | |||
=== Master Patient Index === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|LOCAL PATIENT IDENTIFIER (EXTENDED) | |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. | |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 | ||
| | | | ||
|- | |- | ||
Line 18: | Line 18: | ||
|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 | ||
| | | | ||
|- | |- | ||
|ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) | |ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 30: | Line 28: | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 36: | Line 33: | ||
|The NHS NUMBER STATUS INDICATOR of the PATIENT | |The NHS NUMBER STATUS INDICATOR of the PATIENT | ||
|R | |R | ||
|01- Number present and verified | |01- Number present and verified | ||
Line 54: | Line 50: | ||
|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 | ||
| | | | ||
|- | |- | ||
|POSTCODE OF USUAL ADDRESS | | POSTCODE OF USUAL ADDRESS | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 66: | Line 60: | ||
|The gender identity of a PERSON as stated by the PERSON | |The gender identity of a PERSON as stated by the PERSON | ||
|R | |R | ||
|1- Male (including trans man) | |1- Male (including trans man) | ||
Line 80: | Line 73: | ||
|- | |- | ||
|GENDER IDENTITY SAME AT BIRTH INDICATOR | |GENDER IDENTITY SAME AT BIRTH INDICATOR | ||
|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 | ||
|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 | ||
Line 94: | Line 86: | ||
|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 | ||
| 1- Male | |||
|1- Male | |||
2- Female | 2- Female | ||
Line 105: | Line 96: | ||
|PERSON MARITAL STATUS | |PERSON MARITAL STATUS | ||
|The legal marital status of a PERSON. | |The legal marital status of a PERSON. | ||
|R | | R | ||
| S- Single | |||
|S- Single | |||
M- Married/Civil Partner | M- Married/Civil Partner | ||
Line 126: | Line 116: | ||
|The ethnicity of a PERSON, as specified by the PERSON. | |The ethnicity of a PERSON, as specified by the PERSON. | ||
|R | |R | ||
|A- White - British | |A- White - British | ||
Line 166: | Line 155: | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 172: | Line 160: | ||
|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 | ||
| All Spoken Languages | |||
|All Spoken Languages | |||
ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki> | ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki> | ||
Line 192: | Line 179: | ||
|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 | ||
| | | | ||
|} | |}<br /> | ||
=== GP Practice Registration === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) | | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) | ||
|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 | ||
| | | | ||
|- | |- | ||
|START DATE (GMP PATIENT REGISTRATION) | |START DATE (GMP PATIENT REGISTRATION) | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 218: | Line 202: | ||
|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 | ||
| | | | ||
|} | |}<br /> | ||
=== Accommodation Status === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|ACCOMMODATION TYPE | |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. | |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 | ||
|01- Owner occupier | |01- Owner occupier | ||
Line 280: | Line 262: | ||
|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 | ||
|Y- Yes - Settled Accommodation | |Y- Yes - Settled Accommodation | ||
Line 290: | Line 271: | ||
|- | |- | ||
|ACCOMMODATION TYPE RECORDED DATE | |ACCOMMODATION TYPE RECORDED DATE | ||
|The PERSON PROPERTY RECORDED DATE when the ACCOMMODATION TYPE was recorded. | |The PERSON PROPERTY RECORDED DATE when the ACCOMMODATION TYPE was recorded. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 298: | Line 278: | ||
|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 | ||
|1- Secure welfare placement | |1- Secure welfare placement | ||
Line 306: | Line 285: | ||
|The date that the patient's accommodation type started. | |The date that the patient's accommodation type started. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 312: | Line 290: | ||
|The date that the patient's accommodation type ended. | |The date that the patient's accommodation type ended. | ||
|R | |R | ||
| | | | ||
|} | |}<br /> | ||
=== Employment Status === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | ! Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|EMPLOYMENT STATUS | | EMPLOYMENT STATUS | ||
|The current PRIMARY EMPLOYMENT status of a PERSON. | | The current PRIMARY EMPLOYMENT status of a PERSON. | ||
|M | |M | ||
|01- Employed | |01- Employed | ||
Line 351: | Line 324: | ||
|The date that the patient's employment status started. | |The date that the patient's employment status started. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 357: | Line 329: | ||
|The date that the patient's employment status ended. | |The date that the patient's employment status ended. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
|EMPLOYMENT STATUS RECORDED DATE | |EMPLOYMENT STATUS RECORDED DATE | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 369: | Line 339: | ||
|The number of hours worked in a typical week. | |The number of hours worked in a typical week. | ||
|R | |R | ||
|01- 30+ hours | |01- 30+ hours | ||
Line 383: | Line 352: | ||
99- Number of hours worked not known | 99- Number of hours worked not known | ||
|} | |}<br /> | ||
=== Patient Indicators === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR | |CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR | ||
|An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing. | |An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing. | ||
|R | |R | ||
| | |Y - Yes: PATIENT requires constant care and/or supervision | ||
N - No: PATIENT does not require constant care and/or supervision | |||
|- | |- | ||
|PARENTAL RESPONSIBILITIES INDICATOR | | PARENTAL RESPONSIBILITIES INDICATOR | ||
|An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT. | |An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT. | ||
|R | |R | ||
| | |Y - Yes: PATIENT has parental responsibilities for a child or young person | ||
N - No: PATIENT does not have parental responsibilities for a child or young person | |||
Z - Not Stated (PATIENT asked but declined to provide a response) | |||
X - Not Known (not recorded) | |||
|- | |- | ||
|YOUNG CARER INDICATOR | |YOUNG CARER INDICATOR | ||
|An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling. | | An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling. | ||
|R | |R | ||
| | |Y - Yes: PATIENT has a caring role for an ill or disabled parent, Carer or sibling | ||
N - No: PATIENT does not have a caring role for an ill or disabled parent, Carer or sibling | |||
Z.- Not Stated: (PATIENT asked but declined to provide a response) | |||
X.- Not known whether the PATIENT is a young Carer | |||
|- | |- | ||
|LOOKED AFTER CHILD INDICATOR | |LOOKED AFTER CHILD INDICATOR | ||
|An indication of whether a PATIENT is a Looked After Child. | |An indication of whether a PATIENT is a Looked After Child. | ||
|R | |R | ||
| | |Yes - is a Looked After Child | ||
No - is not a Looked After Child | |||
Not Known if the PATIENT is a Looked After Child | |||
|- | |- | ||
|LOOKED AFTER CHILD LEGAL STATUS | |LOOKED AFTER CHILD LEGAL STATUS | ||
|The legal status of the Looked After Child. This refers to the Children's Act 1989: see details <nowiki>https://www.legislation.gov.uk/ukpga/1989/41/contents</nowiki> | |The legal status of the Looked After Child. This refers to the Children's Act 1989: see details <nowiki>https://www.legislation.gov.uk/ukpga/1989/41/contents</nowiki> | ||
|R | |R | ||
| | |01 - Section 20 Voluntary Agreement | ||
02 = Section 31 Care Order | |||
03 = Section 38 Interim Care Order | |||
08 = Other (not listed) | |||
|- | |- | ||
|EDUCATIONAL ASSESSMENT OUTCOME | |EDUCATIONAL ASSESSMENT OUTCOME | ||
|The outcome of an EDUCATIONAL ASSESSMENT. | | The outcome of an EDUCATIONAL ASSESSMENT. | ||
|R | |R | ||
| | |01 - No Special Education Needs | ||
05 - Subject to Education, Health and Care Plan (EHC) | |||
|- | |- | ||
|CHILD PROTECTION PLAN INDICATION CODE | |CHILD PROTECTION PLAN INDICATION CODE | ||
|An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan. | |An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan. | ||
|R | |R | ||
| | |1 - Has never been subject to a Child Protection Plan | ||
2 - Has previously been subject to a Child Protection Plan | |||
3 - Is currently subject to a Child Protection Plan | |||
X - Not Known whether the PATIENT is or has ever been the subject of a Child Protection Plan | |||
|- | |- | ||
|EX-BRITISH ARMED FORCES INDICATOR | |EX-BRITISH ARMED FORCES INDICATOR | ||
|An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member. | |An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member. | ||
|R | |R | ||
| | |02 - Ex-services member | ||
03 - Not an ex-services member or their dependant | |||
05 - Dependant of an ex-services member | |||
UU - Unknown (PATIENT asked and does not know or is not sure) | |||
ZZ - Not stated (PATIENT asked but declined to provide a response) | |||
|- | |- | ||
|OFFENCE HISTORY INDICATION CODE | |OFFENCE HISTORY INDICATION CODE | ||
Line 448: | Line 457: | ||
This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information. | This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information. | ||
|R | |R | ||
| | |1 - No - No offence | ||
2 - Yes - Less serious offence | |||
3 - Yes - Serious offence | |||
X - Not Known (Not Recorded) | |||
|- | |- | ||
|PRODROME PSYCHOSIS DATE | |PRODROME PSYCHOSIS DATE | ||
Line 456: | Line 470: | ||
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 | ||
| | | | ||
|- | |- | ||
Line 466: | Line 477: | ||
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 | ||
| | | | ||
|- | |- | ||
|MANIFEST PSYCHOSIS DATE | |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. | | 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 | ||
| | | | ||
|- | |- | ||
|FIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION) | |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. | | Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
|PSYCHOSIS FIRST TREATMENT START DATE | | 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). | |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. | Note: For the majority of people this will be the same date as the date of prescription. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 500: | Line 499: | ||
|An indicator to alert the clinician that this patient may need a reasonable adjustment made | |An indicator to alert the clinician that this patient may need a reasonable adjustment made | ||
|R | |R | ||
| | |Y - Yes - the patient requires a Reasonable Adjustment | ||
|} | N - No - the patient does not require a Reasonable Adjustment | ||
|}<br /> | |||
=== Mental Health Care Coordinator === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) | |START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) | ||
|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 | ||
| | | | ||
|- | |- | ||
Line 524: | Line 520: | ||
<br /> | <br /> | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 530: | Line 525: | ||
|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 | ||
| | | | ||
|- | |- | ||
|CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH) | | CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH) | ||
|The type of service or team the Care Professional is associated with. | |The type of service or team the Care Professional is associated with. | ||
|R | |R | ||
| | |A01 Day Care Service | ||
|} | A02 Crisis Resolution Team/Home Treatment Service | ||
A05 Primary Care Mental Health Service | |||
A06 Community Mental Health Team - Functional | |||
A07 Community Mental Health Team - Organic | |||
A08 Assertive Outreach Team | |||
A09 Community Rehabilitation Service | |||
A10 General Psychiatry Service | |||
A11 Psychiatric Liaison Service | |||
A12 Psychotherapy Service | |||
A13 Psychological Therapy Service (non IAPT) | |||
A14 Early Intervention Team for Psychosis | |||
A15 Young Onset Dementia Team | |||
A16 Personality Disorder Service | |||
A17 Memory Services/Clinic/Drop in service | |||
A18 Single Point of Access Service | |||
A19 24/7 Crisis Response Line | |||
A20 Health Based Place Of Safety Service | |||
A21 Crisis Café/Safe Haven/Sanctuary Service | |||
A22 Walk-in Crisis Assessment Unit Service | |||
A23 Psychiatric Decision Unit Service | |||
A24 Acute Day Service | |||
A25 Crisis House Service | |||
B01 Forensic Mental Health Service | |||
B02 Forensic Learning Disability Service | |||
C01 Autism Service | |||
C02 Specialist Perinatal Mental Health Community Service | |||
C04 Neurodevelopment Team | |||
C05 Paediatric Liaison Service | |||
C06 Looked After Children Service | |||
C07 Youth Offending Service | |||
C08 Acquired Brain Injury Service | |||
C10 Community Eating Disorder Service | |||
D01 Substance Misuse Team | |||
D02 Criminal Justice Liaison and Diversion Service | |||
D03 Prison Psychiatric Inreach Service | |||
D04 Asylum Service | |||
D05 Individual Placement and Support Service | |||
D06 Mental Health In Education Service | |||
D07 Problem Gambling Service | |||
D08 Rough Sleeping Service | |||
E01 Community Team for Learning Disabilities | |||
E02 Epilepsy/Neurological Service | |||
E03 Specialist Parenting Service | |||
E04 Enhanced/Intensive Support Service | |||
F01 Mental Health Support Team | |||
F02 Maternal Mental Health Service | |||
F03 Mental Health Services for Deaf people | |||
F04 Veterans Complex Treatment Service | |||
F05 Enhanced care in care homes teams | |||
F06 Mental Health and Wellbeing Hubs | |||
Z01 Other Mental Health Service - in scope of National Tariff Payment System | |||
Z02 Other Mental Health Service - out of scope of National Tariff Payment System | |||
|}<br /> | |||
=== DisabilityType === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|DISABILITY CODE | | DISABILITY CODE | ||
|The DISABILITY of a PERSON. | | The DISABILITY of a PERSON. | ||
This could be where: | This could be where: | ||
Line 559: | Line 653: | ||
the PERSON considers themself to be disabled. | the PERSON considers themself to be disabled. | ||
|M | |M | ||
| | |01 Behaviour and Emotional | ||
02 Hearing | |||
03 Manual Dexterity | |||
04 Memory or ability to concentrate, learn or understand (Learning Disability) | |||
05 Mobility and Gross Motor | |||
06 Perception of Physical Danger | |||
07 Personal, Self Care and Continence | |||
08 Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc) | |||
09 Sight | |||
10 Speech | |||
XX Other (not listed) | |||
NN No Disability | |||
ZZ Not Stated (Person asked but declined to provide a response) | |||
|- | |- | ||
|DISABILITY IMPACT PERCEPTION | | 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. | |The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months. | ||
|R | |R | ||
| | |01 - Yes – limited a lot | ||
| | |||
02 - Yes – limited a little | |||
03 - No - not limited | |||
04 - Prefer not to say (Patient asked but declined to provide a response) | |||
|}<br /> | |||
=== Care Plan Type === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|CARE PLAN IDENTIFIER | | CARE PLAN IDENTIFIER | ||
|A unique identifierfor Care Plan. | | A unique identifierfor Care Plan. | ||
|M | |M | ||
| | | | ||
|- | |- | ||
Line 588: | Line 706: | ||
|The type of Care Plan for the patient, recorded by the service. | |The type of Care Plan for the patient, recorded by the service. | ||
|M | |M | ||
| | |10 - Mental Health Care Plan | ||
11 - Urgent and Emergency Mental Health Care Plan | |||
12 - Mental Health Crisis Plan | |||
13 - Positive Behaviour Support Plan | |||
14 - Child or Young Person's Mental Health Transition Plan | |||
|- | |- | ||
|CARE PLAN CREATION DATE | |CARE PLAN CREATION DATE | ||
|The date that a Care Plan was created for a patient. | |The date that a Care Plan was created for a patient. | ||
|M | |M | ||
| | | | ||
|- | |- | ||
Line 600: | Line 724: | ||
|The time that a Care Plan was created for a patient. | |The time that a Care Plan was created for a patient. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 608: | Line 731: | ||
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date. | Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
Line 616: | Line 738: | ||
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time. | Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time. | ||
|R | |R | ||
| | | | ||
|- | |- | ||
|CARE PLAN IMPLEMENTATION DATE | | CARE PLAN IMPLEMENTATION DATE | ||
|The date that the Care Plan was implemented for a patient. | |The date that the Care Plan was implemented for a patient. | ||
|R | |R | ||
| | | | ||
|} | |}<br /> | ||
=== Care Plan Agreement === | |||
{| class="wikitable" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|FAMILY INVOLVED IN CARE PLAN INDICATOR | |FAMILY INVOLVED IN CARE PLAN INDICATOR | ||
Line 641: | Line 758: | ||
This only needs to be captured for inpatients that are in scope of Transforming Care. | This only needs to be captured for inpatients that are in scope of Transforming Care. | ||
|R | |R | ||
| | |Y - Yes - a member of the patient's family is currently involved in the patient's care plan | ||
N - No - a member of the patient's family is not currently involved in the patient's care plan | |||
9 - Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN | |||
|- | |- | ||
|FAMILY NOT INVOLVED IN CARE PLAN REASON | |FAMILY NOT INVOLVED IN CARE PLAN REASON | ||
Line 651: | Line 769: | ||
This only needs to be captured for inpatients that are in scope of Transforming Care. | This only needs to be captured for inpatients that are in scope of Transforming Care. | ||
|R | |R | ||
| | |01 - At the request of the patient | ||
02 - Access restrictions on the family | |||
03 - No known family | |||
08 - Other (not listed) | |||
|- | |- | ||
|CARE PLAN CONTENT AGREED BY | |CARE PLAN CONTENT AGREED BY | ||
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT. | |The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT. | ||
|M | |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 | |CARE PLAN CONTENT AGREED DATE | ||
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy. | |The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy. | ||
|R | |R | ||
| | |10 - Patient or Patient Proxy | ||
12 - Advocate | |||
13 - Clinical Service or Team | |||
14 - Local Community Support Team | |||
15 - Commissioner | |||
16 - Family member or carer with parental responsibility | |||
17 - Family member or carer without parental responsibility | |||
|- | |- | ||
|CARE PLAN CONTENT AGREED TIME | |CARE PLAN CONTENT AGREED TIME | ||
|The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy | | 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" | {| class="wikitable" | ||
!Name | |||
! | |||
!Description | !Description | ||
!Conformance | !Conformance | ||
! | !Codes & Primary Value Set | ||
|- | |- | ||
|ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) | |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. | |The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on. | ||
|M | |M | ||
| | | | ||
|- | |- | ||
Line 692: | Line 832: | ||
|The date, time and time zone for the prescription of Assistive Technology. | |The date, time and time zone for the prescription of Assistive Technology. | ||
|R | |R | ||
| | | | ||
|}<br /> | |||
=== Social and Personal Circumstances === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|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 | |||
| | |||
|}<br /> | |||
=== Overseas Visitor Charging Category === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|OVERSEAS VISITOR CHARGING CATEGORY | |||
|The charging category relating to an OVERSEAS VISITOR STATUS. | |||
|M | |||
|A - Standard NHS-funded PATIENT | |||
B - Immigration Health Surcharge payee | |||
C - Charge-exempt Overseas Visitor (European Economic Area) | |||
D - Chargeable European Economic Area PATIENT | |||
E - Charge-exempt Overseas Visitor (non-European Economic Area) | |||
F - Chargeable non-European Economic Area PATIENT | |||
P - Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY | |||
9 - OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded) | |||
|- | |||
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE | |||
|The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded. | |||
|R | |||
| | |||
|- | |||
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE | |||
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until. | |||
|R | |||
| | |||
|}<br /> | |||
=== Mental Health Currency Model === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT) | |||
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type. | |||
|P | |||
| | |||
|- | |||
|START DATE (MENTAL HEALTH RESOURCE GROUP) | |||
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group | |||
|P | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH RESOURCE GROUP) | |||
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service. | |||
|P | |||
| | |||
|}<br /> | |||
=== Service or Team Referral === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SERVICE REQUEST IDENTIFIER | |||
|The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned. | |||
|M | |||
| | |||
|- | |||
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) | |||
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care. | |||
|M | |||
| | |||
|- | |||
|REFERRAL REQUEST RECEIVED DATE | |||
|This is the date the REFERRAL REQUEST was received by the Health Care Provider. | |||
|M | |||
| | |||
|- | |||
|REFERRAL REQUEST RECEIVED TIME | |||
|This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care. | |||
|R | |||
| | |||
|- | |||
|NHS SERVICE AGREEMENT LINE NUMBER | |||
|A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES. | |||
|R | |||
| | |||
|- | |||
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE | |||
|The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements. | |||
|R | |||
| | |||
|- | |||
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET | |||
|The source of referral to a Mental Health Service. | |||
|R | |||
|A1 - Primary Health Care: General Medical Practitioner Practice | |||
A2 - Primary Health Care: Health Visitor | |||
A3 - Other Primary Health Care | |||
A4 - Primary Health Care: Maternity Service | |||
B1 - Self-Referral: Self | |||
B2 - Self-Referral: Carer/Relative | |||
C1 - Local Authority and Other Public Services: Social Services | |||
C2 - Local Authority and Other Public Services: Education Service / Educational Establishment | |||
C3 - Local Authority and Other Public Services: Housing Service | |||
D1 - Employer | |||
D2 - Employer: Occupational Health | |||
E1 - Justice System: Police | |||
E2 - Justice System: Courts | |||
E3 - Justice System: Probation Service | |||
E4 - Justice System: Prison | |||
E5 - Justice System: Court Liaison and Diversion Service | |||
E6 - Justice System: Youth Offending Team | |||
F1 - Child Health: School Nurse | |||
F2 - Child Health: Hospital-based Paediatrics | |||
F3 - Child Health: Community-based Paediatrics | |||
G1 - Independent sector - Medium Secure Inpatients | |||
G2 - Independent Sector - Low Secure Inpatients | |||
G3 - Other Independent Sector Mental Health Services | |||
G4 - Voluntary Sector | |||
H1 - Acute Secondary Care: Emergency Care Department | |||
H2 - Other secondary care specialty | |||
I1 - Temporary transfer from another Mental Health NHS Trust | |||
I2 - Permanent transfer from another Mental Health NHS Trust | |||
M1 - Other: Asylum Services | |||
M2 - Other: Telephone or Electronic Access Service | |||
M3 - Other: Out of Area Agency | |||
M4 - Other: Drug Action Team / Drug Misuse Agency | |||
M5 - Other: Jobcentre Plus | |||
M6 - Other SERVICE or agency | |||
M7 - Other: Single Point of Access Service | |||
M9 - Other: Urgent and Emergency Care Ambulance Service | |||
N3 - Improving Access to Psychological Therapies Service | |||
P1 - Internal Referral | |||
Q1 - Mental Health Drop In Service | |||
|- | |||
|ORGANISATION IDENTIFIER (REFERRING) | |||
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust. | |||
|R | |||
| | |||
|- | |||
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) | |||
|The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer. | |||
|R | |||
|A01 Art Therapist | |||
A02 Clinical Psychologist | |||
A03 Dietitian | |||
A04 Dramatherapist | |||
A05 Music Therapist | |||
A06 Occupational Therapist | |||
A07 Orthotist | |||
A08 Physiotherapist | |||
A09 Podiatrist | |||
A10 Prosthetist | |||
A11 Psychotherapist | |||
A12 Radiographer | |||
A13 Speech and Language Therapist | |||
A14 Orthoptist | |||
M01 Community Dentist | |||
M02 Consultant | |||
M03 General Medical Practitioner | |||
M04 General Practitioner with an Extended Role (GPwER) | |||
N01 Midwife | |||
N02 District Nurse | |||
N03 Health Visitor | |||
N04 Macmillan Nurse | |||
N05 School Nurse | |||
N06 Specialist Nursing - Active Case Management (Community Matrons) | |||
N07 Specialist Nursing - Arthritis Nursing/Liaison | |||
N08 Specialist Nursing - Asthma and Respiratory Nursing/Liaison | |||
N09 Specialist Nursing - Breast Care Nursing/Liaison | |||
N10 Specialist Nursing - Cancer Related | |||
N11 Specialist Nursing - Cardiac Nursing/Liaison | |||
N12 Specialist Nursing - Children's Services | |||
N13 Specialist Nursing - Community Cystic Fibrosis | |||
N14 Specialist Nursing - Continence Services | |||
N15 Specialist Nursing - Diabetic Nursing/Liaison | |||
N16 Specialist Nursing - Enteral Feeding Nursing Services | |||
N17 Specialist Nursing - Haemophilia Nursing Services | |||
N19 Specialist Nursing - Infectious Diseases | |||
N20 Specialist Nursing - Intensive Care Nursing | |||
N21 Specialist Nursing - Palliative/Respite Care | |||
N22 Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison | |||
N23 Specialist Nursing - Rehabilitation Nursing | |||
N24 Specialist Nursing - Stoma Care Services | |||
N25 Specialist Nursing - Tissue Viability Nursing/Liaison | |||
N26 Specialist Nursing - Transplantation Patients Nursing Services | |||
N27 Specialist Nursing - Treatment Room Nursing Services | |||
N28 Specialist Nursing - Tuberculosis Specialist Nursing | |||
N29 Specialist Nursing - Other Specialist Nursing | |||
N30 Specialist Nursing - Safeguarding | |||
N31 Practice Nursing | |||
N32 Staff Nurse | |||
N33 Other Registered Nurse | |||
N34 Public Health Nurse | |||
C01 Appliances Technician | |||
C02 Audiologist | |||
C03 Counsellor | |||
C04 Nursery Nurse | |||
C06 Play Therapist | |||
C07 Social Worker | |||
C08 Voluntary Care Worker | |||
C09 Screener (in a National Screening Programme) | |||
C99 Other Care Professional (not listed) | |||
|- | |||
|CLINICAL RESPONSE PRIORITY TYPE | |||
|The clinical response priority of a SERVICE REQUEST. | |||
|R | |||
|1 - Emergency | |||
2 - Urgent/Serious | |||
3 - Routine | |||
4 - Very Urgent | |||
|- | |||
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH) | |||
|This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service | |||
|R | |||
|01 - (Suspected) First Episode Psychosis | |||
02 - Ongoing or Recurrent Psychosis | |||
03 - Bi polar disorder | |||
04 - Depression | |||
05 - Anxiety | |||
06 - Obsessive compulsive disorder | |||
07 - Phobias | |||
08 - Organic brain disorder | |||
09 - Drug and alcohol difficulties | |||
10 - Unexplained physical symptoms | |||
11 - Post-traumatic stress disorder | |||
12 - Eating disorders | |||
13 - Perinatal mental health issues | |||
14 - Personality disorders | |||
15 - Self harm behaviours | |||
16 - Conduct disorders | |||
18 - In crisis | |||
19 - Relationship difficulties | |||
20 - Gender Discomfort issues | |||
21 - Attachment difficulties | |||
22 - Self - care issues | |||
23 - Adjustment to health issues | |||
24 - Neurodevelopmental Conditions, excluding Autism | |||
25 - Suspected Autism | |||
26 - Diagnosed Autism | |||
27 - Preconception perinatal mental health concern | |||
28 - Gambling disorder | |||
29 - Community Perinatal Mental Health Partner Assessment | |||
30 - Behaviours that challenge due to a Learning Disability | |||
|- | |||
|REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH) | |||
|The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES. | |||
|R | |||
|10 - Unavailability of bed at referring organisation | |||
11 - Safeguarding | |||
12 - Offending restrictions | |||
13 - Staff member or family/friend within the referring organisation | |||
14 - Patient choice | |||
15 - Patient away from home | |||
99 - Not Known (Not Recorded) | |||
|- | |||
|DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT) | |||
|The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <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 | |||
| | |||
|- | |||
|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: <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 | |||
| | |||
|- | |||
|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 | |||
| | |||
|}<br /> | |||
=== Other Reason for Referral === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|OTHER REASON FOR REFERRAL (MENTAL HEALTH) | |||
|The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service. | |||
|M | |||
|1 - (Suspected) First Episode Psychosis | |||
2 - Ongoing or Recurrent Psychosis | |||
3 - Bi polar disorder | |||
4 - Depression | |||
5 - Anxiety | |||
6 - Obsessive compulsive disorder | |||
7 - Phobias | |||
8 - Organic brain disorder | |||
9 - Drug and alcohol difficulties | |||
10 - Unexplained physical symptoms | |||
11 - Post-traumatic stress disorder | |||
12 - Eating disorders | |||
13 - Perinatal mental health issues | |||
14 - Personality disorders | |||
15 - Self harm behaviours | |||
16 - Conduct disorders | |||
18 - In crisis | |||
19 - Relationship difficulties | |||
20 - Gender Discomfort issues | |||
21 - Attachment difficulties | |||
22 - Self - care issues | |||
23 - Adjustment to health issues | |||
24 - Neurodevelopmental Conditions, excluding Autism | |||
25 - Suspected Autism | |||
26 - Diagnosed Autism | |||
27 - Preconception perinatal mental health concern | |||
28 - Gambling disorder | |||
29 - Community Perinatal Mental Health Partner Assessment | |||
30 - Behaviours that challenge due to a Learning Disability | |||
|}<br /> | |||
=== Service or Team Type Referred To === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER | |||
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | |||
|R | |||
| | |||
|- | |||
|SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) | |||
|The type of service or team within a Mental Health Service that a patient was referred to | |||
|M | |||
|A01 Day Care Service | |||
A02 Crisis Resolution Team/Home Treatment Service | |||
A05 Primary Care Mental Health Service | |||
A06 Community Mental Health Team - Functional | |||
A07 Community Mental Health Team - Organic | |||
A08 Assertive Outreach Team | |||
A09 Community Rehabilitation Service | |||
A10 General Psychiatry Service | |||
A11 Psychiatric Liaison Service | |||
A12 Psychotherapy Service | |||
A13 Psychological Therapy Service (non IAPT) | |||
A14 Early Intervention Team for Psychosis | |||
A15 Young Onset Dementia Team | |||
A16 Personality Disorder Service | |||
A17 Memory Services/Clinic/Drop in service | |||
A18 Single Point of Access Service | |||
A19 24/7 Crisis Response Line | |||
A20 Health Based Place Of Safety Service | |||
A21 Crisis Café/Safe Haven/Sanctuary Service | |||
A22 Walk-in Crisis Assessment Unit Service | |||
A23 Psychiatric Decision Unit Service | |||
A24 Acute Day Service | |||
A25 Crisis House Service | |||
B01 Forensic Mental Health Service | |||
B02 Forensic Learning Disability Service | |||
C01 Autism Service | |||
C02 Specialist Perinatal Mental Health Community Service | |||
C04 Neurodevelopment Team | |||
C05 Paediatric Liaison Service | |||
C06 Looked After Children Service | |||
C07 Youth Offending Service | |||
C08 Acquired Brain Injury Service | |||
C10 Community Eating Disorder Service | |||
D01 Substance Misuse Team | |||
D02 Criminal Justice Liaison and Diversion Service | |||
D03 Prison Psychiatric Inreach Service | |||
D04 Asylum Service | |||
D05 Individual Placement and Support Service | |||
D06 Mental Health In Education Service | |||
D07 Problem Gambling Service | |||
D08 Rough Sleeping Service | |||
E01 Community Team for Learning Disabilities | |||
E02 Epilepsy/Neurological Service | |||
E03 Specialist Parenting Service | |||
E04 Enhanced/Intensive Support Service | |||
F01 Mental Health Support Team | |||
F02 Maternal Mental Health Service | |||
F03 Mental Health Services for Deaf people | |||
F04 Veterans Complex Treatment Service | |||
F05 Enhanced care in care homes teams | |||
F06 Mental Health and Wellbeing Hubs | |||
Z01 Other Mental Health Service - in scope of National Tariff Payment System | |||
Z02 Other Mental Health Service - out of scope of National Tariff Payment System | |||
|- | |||
|REFERRAL CLOSURE DATE | |||
|The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | |||
|R | |||
| | |||
|- | |||
|REFERRAL CLOSURE TIME | |||
|The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | |||
|R | |||
| | |||
|- | |||
|REFERRAL REJECTION DATE | |||
|The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | |||
|R | |||
| | |||
|- | |||
|REFERRAL REJECTION TIME | |||
|The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | |||
|R | |||
| | |||
|- | |||
|REFERRAL CLOSURE REASON | |||
|The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set. | |||
|R | |||
|01 - Admitted elsewhere (at the same or other Health Care Provider) | |||
02 - Treatment completed | |||
03 - Moved out of the area | |||
04 - No further treatment appropriate | |||
05 - Patient did not attend | |||
06 - Patient died | |||
07 - Patient requested discharge | |||
08 - Referred to other specialty/Service (at the same or other Health Care Provider) | |||
09 - PATIENT refused to be seen | |||
|- | |||
|REFERRAL REJECTION REASON | |||
|The reason that a Referral Request has been rejected by the SERVICE. | |||
|R | |||
|01 - Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider) | |||
02 - Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider) | |||
03 - Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST) | |||
|}<br /> | |||
=== Referral to Treatment (RTT) === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PATIENT PATHWAY IDENTIFIER | |||
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY. | |||
|R | |||
| | |||
|- | |||
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) | |||
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER. | |||
|R | |||
| | |||
|- | |||
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH) | |||
|The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy. | |||
|M | |||
|02 - Allied Health Professional Referral To Treatment Measurement | |||
09 - Other Referral To Treatment Measurement Type (not listed) | |||
|- | |||
|REFERRAL TO TREATMENT PERIOD START DATE | |||
|The start date of a REFERRAL TO TREATMENT PERIOD. | |||
|R | |||
| | |||
|- | |||
|REFERRAL TO TREATMENT PERIOD END DATE | |||
|The end date of a REFERRAL TO TREATMENT PERIOD. | |||
|R | |||
| | |||
|- | |||
|REFERRAL TO TREATMENT PERIOD STATUS | |||
|The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL. | |||
|R | |||
|10 - First activity in a Referral to Treatment Period | |||
11 - First activity at the start of a new Referral to Treatment Period following Active Monitoring | |||
12 - First activity at the start of a new Referral to Treatment Period following a decision to refer directly to the consultant or NHS Allied Health Professional Service (Referral To Treatment Measurement) for a separate condition | |||
20 - Subsequent activity during a Referral to Treatment Period - further activities anticipated | |||
21 - Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated | |||
30 - End of the Referral to Treatment Period: Start of First Definitive Treatment | |||
31 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient | |||
32 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional | |||
33 - End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral | |||
34 - End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required | |||
35 - End of the Referral to Treatment Period: patient declined offered treatment | |||
36 - End of the Referral to Treatment Period: patient died before treatment | |||
90 - Not part of a Referral to Treatment Period: After treatment - First Definitive Treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment) | |||
91 - Not part of a Referral to Treatment Period: Care activity during Active Monitoring | |||
92 - Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral | |||
98 - Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods | |||
99 - Referral to Treatment Period status not yet known | |||
|}<br /> | |||
=== Onward Referral === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DECISION TO REFER DATE (ONWARD REFERRAL) | |||
|DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. | |||
|R | |||
| | |||
|- | |||
|DECISION TO REFER TIME (ONWARD REFERRAL) | |||
|DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. | |||
|R | |||
| | |||
|- | |||
|ONWARD REFERRAL DATE | |||
|The date the patient was referred to another service, which may be in the same or a different organisation. | |||
|M | |||
| | |||
|- | |||
|ONWARD REFERRAL TIME | |||
|The time the patient was referred to another service, which may be in the same or a different organisation. | |||
|R | |||
| | |||
|- | |||
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET) | |||
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation. | |||
|R | |||
|01 - Transfer of Clinical Responsibility | |||
02 - For Opinion Only | |||
03 - For Diagnostic Test Only | |||
04 - New Referral (Non Transfer) | |||
96 - Other (not listed) | |||
98 - Onward Referral Reason Not Applicable | |||
99 - Not Known (Not Recorded) | |||
|- | |||
|REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH) | |||
|The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy. | |||
|R | |||
|10 - Unavailability of bed at referring organisation | |||
11 - Safeguarding | |||
12 - Offending restrictions | |||
13 - Staff member or family/friend within the referring organisation | |||
14 - Patient choice | |||
99 - Not Known (Not Recorded) | |||
|- | |||
|ORGANISATION IDENTIFIER (RECEIVING) | |||
|ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider. | |||
|R | |||
| | |||
|- | |||
|CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | |||
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed. | |||
|R | |||
| | |||
|}<br /> | |||
=== Discharge Plan Agreement === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DISCHARGE PLAN CONTENT AGREED BY | |||
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT. | |||
|M | |||
|10 - Patient or Patient Proxy | |||
12 - Advocate | |||
13 - Clinical Service or Team | |||
14 - Local Community Support Team | |||
15 - Current Commissioner | |||
16 - Commissioner of Planned Discharge Destination | |||
17 - Family member or carer with parental responsibility | |||
18 - Family member or carer without parental responsibility | |||
|- | |||
|DISCHARGE PLAN CONTENT AGREED DATE | |||
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. | |||
|R | |||
| | |||
|- | |||
|DISCHARGE PLAN CONTENT AGREED TIME | |||
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. | |||
|R | |||
| | |||
|}<br /> | |||
=== Medication Prescription === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PRESCRIPTION IDENTIFIER | |||
|The unique identifier of a PRESCRIPTION. | |||
|P | |||
| | |||
|- | |||
|PRESCRIPTION DATE (MEDICATION) | |||
|The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|- | |||
|PRESCRIPTION TIME (MEDICATION) | |||
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|}<br /> | |||
=== Care Contact === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE CONTACT IDENTIFIER | |||
|The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned. | |||
|M | |||
| | |||
|- | |||
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER | |||
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | |||
|R | |||
| | |||
|- | |||
|CARE CONTACT DATE | |||
|The date on which a Care Contact took place, or, if cancelled, was scheduled to take place. | |||
|M | |||
| | |||
|- | |||
|CARE CONTACT TIME | |||
|The time at which a Care Contact took place. | |||
|R | |||
| | |||
|- | |||
|ADMINISTRATIVE CATEGORY CODE | |||
|This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed. | |||
|R | |||
|01 - NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations) | |||
02 - Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006 | |||
03 - Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006 | |||
04 - Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff. | |||
98 - Not applicable | |||
99 - ADMINISTRATIVE CATEGORY CODE not known | |||
|- | |||
|CLINICAL CONTACT DURATION OF CARE CONTACT | |||
|The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes. | |||
|R | |||
| | |||
|- | |||
|CONSULTATION TYPE | |||
|The type of consultation between the CARE PROFESSIONAL and the PATIENT. | |||
|R | |||
|01 - Initial Consultation | |||
02 - Follow-up Consultation | |||
|- | |||
|CARE CONTACT SUBJECT | |||
|The person who was the subject of the Care Contact. | |||
|R | |||
|01 - Patient | |||
02 - Patient Proxy | |||
|- | |||
|CONSULTATION MECHANISM (MENTAL HEALTH) | |||
|The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS. | |||
|R | |||
|01 - Face to face | |||
02 - Telephone | |||
04 - Talk type for a person unable to speak | |||
05 - Email | |||
09 - Text Message (Asynchronous) | |||
10 - Instant messaging (Synchronous) | |||
11 - Video consultation | |||
12 - Message Board (Asynchronous) | |||
13 - Chat Room (Synchronous) | |||
98 - Other (not listed) | |||
|- | |||
|ACTIVITY LOCATION TYPE CODE | |||
|The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent. | |||
|R | |||
|A01 Patient's home | |||
A02 Carer's home | |||
A03 Patient's workplace | |||
A04 Other patient related location | |||
B01 Primary Care Health Centre | |||
B02 Polyclinic | |||
C01 General Medical Practitioner Practice | |||
C02 Dental Practice | |||
C03 Ophthalmic Medical Practitioner premises | |||
D01 Walk In Centre | |||
D02 Out of Hours Centre | |||
D03 Emergency Community Dental Service | |||
E01 Out-Patient Clinic | |||
E02 Ward | |||
E03 Day Hospital | |||
E04 Emergency Care Department or Minor Injuries Department | |||
E99 Other departments | |||
F01 Hospice | |||
G01 Care Home Without Nursing | |||
G02 Care Home With Nursing | |||
G03 Children’s Home | |||
G04 Integrated Care Home Without Nursing and Care Home With Nursing | |||
H01 Day Centre | |||
J01 Resource Centre | |||
K01 Sure Start Children’s Centre | |||
K02 Child Development Centre | |||
L01 School | |||
L02 Further Education College | |||
L03 University | |||
L04 Nursery Premises | |||
L05 Other Childcare Premises | |||
L06 Training Establishments | |||
L99 Other Educational Premises | |||
M01 Prison | |||
M02 Probation Service Premises | |||
M03 Police Station / Police Custody Suite | |||
M04 Young Offender Institution | |||
M06 Young Offender Institution (15-17) | |||
M07 Young Offender Institution (18-21) | |||
M05 Immigration Removal Centre | |||
N01 Street or other public open space | |||
N02 Other publicly accessible area or building | |||
N03 Voluntary or charitable agency premises | |||
N04 Dispensing Optician premises | |||
N05 Dispensing Pharmacy premises | |||
X01 Other locations not elsewhere classified | |||
1 General Health Promotion Session | |||
2 Telephone Support Sessiom | |||
3 Thereputic Group Session | |||
|- | |||
|PLACE OF SAFETY INDICATOR | |||
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY. | |||
|R | |||
|Y - Yes – is being used as a Place of Safety | |||
N - No – is not being used as a Place of Safety | |||
|- | |||
|ORGANISATION SITE IDENTIFIER (OF TREATMENT) | |||
|The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated. | |||
|R | |||
| | |||
|- | |||
|COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR | |||
|An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service. | |||
|R | |||
|Y - Yes - a Community Perinatal Mental Health Partner Assessment has been offered | |||
N - No - a Community Perinatal Mental Health Partner Assessment has not been offered | |||
|- | |||
|PLANNED CARE CONTACT INDICATOR | |||
|An indication as to whether a Care Contact is a result of a Planned Appointment. | |||
|R | |||
|Y - Yes - the care contact is a result of a planned Appointment | |||
N - No - the care contact is not a result of a planned appointment | |||
|- | |||
|CARE CONTACT PATIENT THERAPY MODE | |||
|The mode of therapy for the patient during a Care Contact. | |||
|R | |||
|1 - Individual patient | |||
2 - Couple | |||
3 - Group Therapy | |||
|- | |||
|ATTENDED OR DID NOT ATTEND CODE | |||
|This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given. | |||
|R | |||
|5 - Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT | |||
6 - Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen | |||
7 - Patient arrived late and could not be seen | |||
2 - APPOINTMENT cancelled by, or on behalf of, the PATIENT | |||
3 - Did not attend - no advance warning given | |||
4 - Appointment cancelled or postponed by the health care provider | |||
|- | |||
|EARLIEST REASONABLE OFFER DATE | |||
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission. | |||
|R | |||
| | |||
|- | |||
|EARLIEST CLINICALLY APPROPRIATE DATE | |||
|The earliest DATE that it was clinically appropriate for an ACTIVITY to take place. | |||
|R | |||
| | |||
|- | |||
|CARE CONTACT CANCELLATION DATE | |||
|The date that a Care Contact was cancelled by the Provider or Patient. | |||
|R | |||
| | |||
|- | |||
|CARE CONTACT CANCELLATION REASON | |||
|The reason that a Care Contact was cancelled. | |||
|R | |||
|01 - Cancelled for Clinical Reasons | |||
02 - Cancelled for Non-clinical Reasons | |||
|- | |||
|REASONABLE ADJUSTMENT MADE INDICATOR | |||
|Was a reasonable adjustment made for this patient? | |||
|R | |||
|Y - Yes - a Reasonable Adjustment was made for the patient | |||
N - No - a Reasonable Adjustment was not made for the patient | |||
X - Not applicable | |||
|}<br /> | |||
=== Care Activity === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE ACTIVITY IDENTIFIER | |||
|The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned. | |||
|M | |||
| | |||
|- | |||
|CLINICAL CONTACT DURATION OF CARE ACTIVITY | |||
|The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY. | |||
|R | |||
| | |||
|- | |||
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | |||
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. | |||
|R | |||
| | |||
|- | |||
|FINDING SCHEME IN USE (MENTAL HEALTH) | |||
|The code scheme basis of a finding. | |||
|R | |||
|01 - ICD-10 | |||
04 - SNOMED CT® | |||
|- | |||
|CODED FINDING (CODED CLINICAL ENTRY) | |||
|A unique identifier for a finding from a specific classification or clinical terminology. | |||
|R | |||
| | |||
|- | |||
|CODED OBSERVATION (SNOMED CT) | |||
|A unique identifier for an observation from a specific clinical terminology. | |||
|R | |||
| | |||
|- | |||
|OBSERVATION VALUE | |||
|The numeric value resulting from a clinical observation. | |||
|R | |||
| | |||
|- | |||
|UCUM UNIT OF MEASUREMENT | |||
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>. | |||
|R | |||
| | |||
|}<br /> | |||
=== Other in Attendance === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT | |||
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT. | |||
|M | |||
|01 - Independent Advocate (Family Member) | |||
02 - Independent Advocate (Independent Person) | |||
03 - Independent Mental Capacity Advocate (IMCA) | |||
04 - Independent Mental Health Advocate (IMHA) | |||
05 - Non-Instructed Advocate | |||
10 - Parent or relative (Non-Advocate) | |||
11 - Friend or neighbour (Non-Advocate) | |||
12 - Care Worker (Non-Advocate) | |||
|- | |||
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE | |||
|Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care | |||
|R | |||
|01 - PATIENT has chosen not to have an Independent Mental Health Advocate | |||
02 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken | |||
03 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought | |||
04 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken | |||
05 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought | |||
98 - Other (not listed) | |||
99 - Not applicable (no requirement for an Independent Mental Capacity Advocate) | |||
|- | |||
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE | |||
|Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care | |||
|R | |||
|01 - Patient has chosen not to have an Independent Mental Health Advocate | |||
02 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken | |||
03 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought | |||
04 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken | |||
05 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought | |||
98 - Other (not listed) | |||
99 - Not applicable (no requirement for an Independent Mental Health Advocate) | |||
|}<br /> | |||
=== Indirect Activity === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|INDIRECT ACTIVITY DATE | |||
|The date that the indirect activity took place | |||
|M | |||
| | |||
|- | |||
|INDIRECT ACTIVITY TIME | |||
|The time that the indirect activity took place | |||
|R | |||
| | |||
|- | |||
|DURATION OF INDIRECT ACTIVITY | |||
|The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided. | |||
|R | |||
| | |||
|- | |||
|CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | |||
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed. | |||
|R | |||
| | |||
|}<br /> | |||
=== Group Session === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|GROUP SESSION IDENTIFIER | |||
|The GROUP SESSION IDENTIFIER is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned. | |||
|M | |||
| | |||
|- | |||
|GROUP SESSION DATE | |||
|The date that a Group Session took place, or, if cancelled, was scheduled to take place. | |||
|M | |||
| | |||
|- | |||
|CLINICAL CONTACT DURATION OF GROUP SESSION | |||
|The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided. | |||
|R | |||
| | |||
|- | |||
|GROUP SESSION TYPE (MENTAL HEALTH) | |||
|The type of Group Session provided by a Mental Health Service. | |||
|R | |||
|01 - General Health Promotion Session | |||
02 - Telephone Support Session | |||
03 - Therapeutic Group Session | |||
|- | |||
|NUMBER OF GROUP SESSION PARTICIPANTS | |||
|The number of persons who participated in the Group Session excluding the care professionals. | |||
|R | |||
| | |||
|}<br /> | |||
=== Mental Health Drop In Contact === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|MENTAL HEALTH DROP IN CONTACT IDENTIFIER | |||
|The Mental Health DROP IN CONTACT IDENTIFIER is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned. | |||
|M | |||
| | |||
|- | |||
|CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT) | |||
|The date that a Drop In Contact took place. | |||
|M | |||
| | |||
|- | |||
|MENTAL HEALTH DROP IN CONTACT SERVICE TYPE | |||
|The type of SERVICE where the Mental Health Drop In Contact took place. | |||
|R | |||
|A17 - Memory Services/Clinic/Drop In Service | |||
A19 - 24/7 Crisis Response Line | |||
A21 - Crisis Café/Safe Haven/Sanctuary Service | |||
|- | |||
|START TIME (MENTAL HEALTH DROP IN CONTACT) | |||
|The Start Time of the Mental Health Drop In Contact as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|END TIME (MENTAL HEALTH DROP IN CONTACT) | |||
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|MENTAL HEALTH DROP IN CONTACT OUTCOME | |||
|The outcome of the Mental Health Drop In Contact as reported by the Care Professional. | |||
|R | |||
|01 - Caller Disconnected | |||
02 - Advice on call only | |||
03 - Signposted to other non-NHS services sources of support | |||
04 - Non-urgent referral to other NHS service | |||
05 - Urgent referral for face to face assessment | |||
06 - Emergency Service(s) notified | |||
98 - Other (not listed) | |||
|}<br /> | |||
=== Mental Health Act Legal Status Classification Assignment Period === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER | |||
|A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. | |||
|M | |||
| | |||
|- | |||
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | |||
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period. | |||
|M | |||
| | |||
|- | |||
|START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | |||
|The Start Time of the Mental Health Act Legal Status Classification Assignment Period. | |||
|M | |||
| | |||
|- | |||
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON | |||
|The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period. | |||
|R | |||
|01 - Change in Mental Health Act Legal Status Classification Code (including from informal) | |||
04 - Transfer from other Health Care Provider | |||
|- | |||
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) | |||
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. | |||
|R | |||
| | |||
|- | |||
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) | |||
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. | |||
|R | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | |||
|The date on which the Mental Health Act Legal Status Classification Assignment Period ended. | |||
|R | |||
| | |||
|- | |||
|END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | |||
|The time on which the Mental Health Act Legal Status Classification Period ended. | |||
|R | |||
| | |||
|- | |||
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON | |||
|The reason for the end of the Mental Health Act Legal Status Classification Assignment Period. | |||
|R | |||
|01 - Change in Mental Health Act Legal Status Classification Code (including to informal) | |||
04 - Transfer to other Health Care Provider | |||
05 - Death of patient | |||
|- | |||
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE | |||
|'A code to identify the classification of Mental Health Act Legal Status. | |||
|R | |||
|01 - Informal | |||
02 - Formally detained under Mental Health Act Section 2 | |||
03 - Formally detained under Mental Health Act Section 3 | |||
04 - Formally detained under Mental Health Act Section 4 | |||
05 - Formally detained under Mental Health Act Section 5 (2) | |||
06 - Formally detained under Mental Health Act Section 5 (4) | |||
07 - Formally detained under Mental Health Act Section 35 | |||
08 - Formally detained under Mental Health Act Section 36 | |||
09 - Formally detained under Mental Health Act Section 37 with section 41 restrictions | |||
10 - Formally detained under Mental Health Act Section 37 | |||
12 - Formally detained under Mental Health Act Section 38 | |||
13 - Formally detained under Mental Health Act Section 44 | |||
14 - Formally detained under Mental Health Act Section 46 | |||
15 - Formally detained under Mental Health Act Section 47 with section 49 restrictions | |||
16 - Formally detained under Mental Health Act Section 47 | |||
17 - Formally detained under Mental Health Act Section 48 with section 49 restrictions | |||
18 - Formally detained under Mental Health Act Section 48 | |||
19 - Formally detained under Mental Health Act Section 135 | |||
20 - Formally detained under Mental Health Act Section 136 | |||
31 - Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991 | |||
32 - Formally detained under other acts | |||
35 - Subject to guardianship under Mental Health Act Section 7 | |||
36 - Subject to guardianship under Mental Health Act Section 37 | |||
37 - Formally detained under Mental Health Act Section 45A (Limited direction in force) | |||
38 - Formally detained under Mental Health Act Section 45A (Limitation direction ended) | |||
98 - Not Applicable | |||
99 - Not Known | |||
|- | |||
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY | |||
|The primary reason for the detention of PATIENTS. | |||
|R | |||
|A - Mental disorder (Learning Disability not present or not primary reason for using Act) | |||
B - Mental disorder (Learning Disability primary reason for using Act) | |||
8 - Not applicable (i.e. not detained) | |||
9 - Not Known (Not Recorded) | |||
|}<br /> | |||
=== Mental Health Responsible Clinician Assignment Period === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) | |||
|The start date of an assignment of a Mental Health Responsible Clinician to a patient. | |||
|M | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) | |||
|The end date of an assignment of a Mental Health Responsible Clinician to a patient. | |||
|R | |||
| | |||
|}<br /> | |||
=== Conditional Discharge === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) | |||
|The start date of the Mental Health Conditional Discharge Period. | |||
|M | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) | |||
|The end date of the Mental Health Conditional Discharge Period. | |||
|R | |||
| | |||
|- | |||
|MENTAL HEALTH CONDITIONAL DISCHARGE END REASON | |||
|The reason a Mental Health Conditional Discharge Period ended. | |||
|R | |||
|01 - Mental Health absolute discharge | |||
02 - Recall of PATIENT | |||
03 - Death of PATIENT | |||
|- | |||
|MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY | |||
|The body or PERSON responsible for granting Mental Health Absolute Discharge. | |||
|R | |||
|01 - Mental Health Tribunal | |||
02 - Secretary of State | |||
|}<br /> | |||
=== Community Treatment Order Recall === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (COMMUNITY TREATMENT ORDER RECALL) | |||
|The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | |||
|M | |||
| | |||
|- | |||
|EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL) | |||
|The date which the Community Treatment Order for a patient was due to expire. This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended | |||
|R | |||
| | |||
|- | |||
|END DATE (COMMUNITY TREATMENT ORDER RECALL) | |||
|The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | |||
|R | |||
| | |||
|- | |||
|COMMUNITY TREATMENT ORDER END REASON | |||
|The reason for the termination of a period of a Community Treatment Order. | |||
|R | |||
|01 - Patient discharged | |||
02 - Community Treatment Order revoked | |||
03 - Patient died | |||
04 - Patient transferred outside England | |||
05 - Patient transferred to another Health Care Provider | |||
|}<br /> | |||
=== Community Treatment Order Recall === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START TIME (COMMUNITY TREATMENT ORDER RECALL) | |||
|The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | |||
|M | |||
| | |||
|- | |||
|END TIME (COMMUNITY TREATMENT ORDER RECALL) | |||
|The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | |||
|R | |||
| | |||
|}<br /> | |||
=== Hospital Provider Spell === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|HOSPITAL PROVIDER SPELL IDENTIFIER | |||
|A unique identifier for each Hospital Provider Spell for a Health Care Provider. | |||
|M | |||
| | |||
|- | |||
|DECIDED TO ADMIT DATE | |||
|The date a DECISION TO ADMIT was made. | |||
|R | |||
| | |||
|- | |||
|DECIDED TO ADMIT TIME | |||
|The time a DECISION TO ADMIT was made. | |||
|R | |||
| | |||
|- | |||
|START DATE (HOSPITAL PROVIDER SPELL) | |||
|The start date of a Hospital Provider Spell. | |||
|M | |||
| | |||
|- | |||
|START TIME (HOSPITAL PROVIDER SPELL) | |||
|The start time of a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | |||
|The source of admission to a Hospital Provider Spell. | |||
|R | |||
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode. | |||
29 - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments) | |||
37 - Court | |||
40 - Penal establishment | |||
42 - Police Station / Police Custody Suite | |||
49 - NHS other Hospital Provider - high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) | |||
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department | |||
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates | |||
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities | |||
55 - Care Home With Nursing | |||
56 - Care Home Without Nursing | |||
66 - Local Authority foster care | |||
87 - Independent Sector Healthcare Provider run hospital | |||
88 - Hospice | |||
98 - Not applicable | |||
99 - Not Known | |||
|- | |||
|METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | |||
|The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission. | |||
|R | |||
|11 - Elective Admission: Waiting list | |||
12 - Elective Admission: Booked | |||
13 - Elective Admission: Planned | |||
21 - Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE | |||
22 - Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy | |||
23 - Emergency Admission: Bed bureau | |||
24 - Emergency Admission: Consultant Clinic, of this or another Health Care Provider | |||
25 - Emergency Admission: Admission via Mental Health Crisis Resolution Team | |||
2A - Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted | |||
2B - Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency | |||
2D - Emergency Admission: Other emergency admission | |||
81 - Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency | |||
98 - Not applicable | |||
99 - Not Known | |||
|- | |||
|POSTCODE OF MAIN VISITOR | |||
|The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | |||
|The estimated discharge date from a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | |||
|The planned discharge date from a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) | |||
|The planned destination of a PATIENT on completion of a Hospital Provider Spell. | |||
|R | |||
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode. | |||
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment) | |||
30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) | |||
37 - Court | |||
40 - Penal establishment | |||
42 - Police Station / Police Custody Suite | |||
48 - High Security Psychiatric Hospital, Scotland | |||
49 - NHS other Hospital Provider - high security psychiatric accommodation | |||
50 - NHS other Hospital Provider - medium secure unit | |||
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled | |||
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates | |||
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities | |||
55 - Care Home With Nursing | |||
56 - Care Home Without Nursing | |||
66 - Local Authority foster care | |||
79 - PATIENT died or stillbirth | |||
84 - Independent Sector Healthcare Provider run hospital - medium secure unit | |||
87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit | |||
88 - Hospice | |||
89 - ORGANISATION responsible for forced repatriation | |||
98 - Not applicable | |||
99 - Not known | |||
|- | |||
|DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | |||
|The discharge date from a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|DISCHARGE TIME (HOSPITAL PROVIDER SPELL) | |||
|The discharge time from a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | |||
|The method of discharge from a Hospital Provider Spell. | |||
|R | |||
|1 - Patient discharged on clinical advice or with clinical consent | |||
3 - Patient discharged by mental health review tribunal, Home Secretary or court | |||
4 - Patient died | |||
6 - Patient discharged him/herself | |||
7 - Patient discharged by a relative or advocate | |||
8 - Not applicable (Hospital Provider Spell not finished at episode end (i.e. not discharged) or current episode unfinished) | |||
9 - Method of Discharge not known | |||
|- | |||
|DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) | |||
|The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died. | |||
|R | |||
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode. | |||
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment) | |||
30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) | |||
37 - Court | |||
40 - Penal establishment | |||
42 - Police Station / Police Custody Suite | |||
48 - High Security Psychiatric Hospital, Scotland | |||
49 - NHS other Hospital Provider - high security psychiatric accommodation | |||
50 - NHS other Hospital Provider - medium secure unit | |||
51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled | |||
52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates | |||
53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities | |||
55 - Care Home With Nursing | |||
56 - Care Home Without Nursing | |||
66 - Local Authority foster care | |||
79 - PATIENT died or stillbirth | |||
84 - Independent Sector Healthcare Provider run hospital - medium secure unit | |||
87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit | |||
88 - Hospice | |||
89 - ORGANISATION responsible for forced repatriation | |||
98 - Not applicable | |||
99 - Not known | |||
|- | |||
|POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) | |||
|The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell. | |||
|R | |||
| | |||
|- | |||
|TRANSFORMING CARE INDICATOR | |||
|Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care | |||
|R | |||
|Y - Yes - Patient is in scope of transforming care | |||
N - No - Patient is not in scope of transforming care | |||
|- | |||
|TRANSFORMING CARE CATEGORY | |||
|Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care | |||
|R | |||
|1 - Patient with autism (and no learning disability) | |||
2 - Patient with a learning disability (and no autism) | |||
3 - Patient with autism and a learning disability | |||
|}<br /> | |||
=== Ward Stay === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|WARD STAY IDENTIFIER | |||
|A unique identifier allocated for each Ward Stay during the hospital provider spell. | |||
|M | |||
| | |||
|- | |||
|START DATE (WARD STAY) | |||
|The start date of a ward stay. | |||
|M | |||
| | |||
|- | |||
|START TIME (WARD STAY) | |||
|The start time of a ward stay. | |||
|R | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH TRIAL LEAVE) | |||
|The End Date of a period of Mental Health Trial Leave for a PATIENT. | |||
|R | |||
| | |||
|- | |||
|END DATE (WARD STAY) | |||
|The end date of a ward stay. | |||
|R | |||
| | |||
|- | |||
|END TIME (WARD STAY) | |||
|The end time of a ward stay. | |||
|R | |||
| | |||
|- | |||
|WARD SETTING TYPE (MENTAL HEALTH) | |||
|The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell. | |||
|R | |||
|01 - Child and Adolescent Mental Health Ward | |||
02 - Paediatric Ward | |||
03 - Adult Mental Health Ward | |||
04 - Non Mental Health Ward | |||
05 - Learning Disabilities Ward | |||
06 - Older People's Mental Health Ward | |||
|- | |||
|INTENDED AGE GROUP (MENTAL HEALTH) | |||
|The age group of PATIENTS intended to use a WARD indicated in the operational plan. | |||
|R | |||
|10 - Child only | |||
11 - Adolescent only | |||
12 - Child and Adolescent | |||
13 - Adult only | |||
14 - Older Adult only | |||
15 - Adult and Older Adult | |||
99 - Any age | |||
|- | |||
|SEX OF PATIENTS CODE (MENTAL HEALTH) | |||
|The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed. | |||
|R | |||
|1 - Male | |||
2 - Female | |||
8 - Not specified | |||
|- | |||
|INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) | |||
|The intended level of resources and intensity of care for the ward in which the person is placed. | |||
|R | |||
|51 - Mental Illness intensive care: specially designated ward for Patients needing containment and more intensive management (e.g. Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where Patients may require one to one nursing while on a standard ward | |||
52 - Mental Illness short stay: Patients intended to stay less than a year | |||
53 - Mental Illness long stay: Patients intended to stay a year or more | |||
61 - Learning Disability Patients in a designated or interim secure unit | |||
62 - Learning Disability Patients intending to stay less than a year | |||
63 - Learning Disability Patients intending to stay a year or more | |||
|- | |||
|WARD SECURITY LEVEL | |||
|The level of security for a ward. | |||
|R | |||
|0 - General (non-secure) | |||
1 - Low Secure | |||
2 - Medium Secure | |||
3 - High Secure | |||
|- | |||
|LOCKED WARD INDICATOR | |||
|An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit. | |||
|R | |||
|Y - Yes - is a locked WARD | |||
N - No - is not a locked WARD | |||
|- | |||
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION | |||
|The classification of the admitted PATIENT during a Ward Stay. | |||
|R | |||
|10 - Acute adult mental health care | |||
11 - Acute older adult mental health care (organic and functional) | |||
12 - Adult Psychiatric Intensive Care Unit (acute mental health care) | |||
13 - Adult Eating Disorders | |||
14 - Mother and baby | |||
15 - Adult Learning Disabilities | |||
17 - Adult High dependency rehabilitation | |||
19 - Adult Low secure | |||
20 - Adult Medium secure | |||
21 - Adult High secure | |||
22 - Adult Neuro-psychiatry / Acquired Brain Injury | |||
23 - General child and young PERSON admitted PATIENT - Child (including High Dependency) | |||
24 - General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency) | |||
25 - Eating Disorders admitted patient - Young person (13 years and over) | |||
26 - Eating Disorders admitted patient - Child (12 years and under) | |||
27 - Child and Young Person Low Secure Mental Illness | |||
28 - Child and Young Person Medium Secure Mental Illness | |||
29 - Child Mental Health admitted patient services for the Deaf | |||
30 - Child and Young Person Learning Disabilities / Autism admitted patient | |||
31 - Child and Young Person Low Secure Learning Disabilities | |||
32 - Child and Young Person Medium Secure Learning Disabilities | |||
33 - Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person | |||
34 - Child and Young Person Psychiatric Intensive Care Unit | |||
35 - Adult admitted patient continuing care | |||
36 - Adult community rehabilitation unit | |||
37 - Adult highly specialist high dependency rehabilitation unit | |||
38 - Adult longer term high dependency rehabilitation unit | |||
39 - Adult mental health admitted patient services for the Deaf | |||
40 - Adult personality disorder | |||
|- | |||
|WARD CODE | |||
|A unique identification of a WARD within a Health Care Provider. | |||
|R | |||
| | |||
|}<br /> | |||
=== Assigned Care Professional === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) | |||
|The start date of an assignment of a Care Professional responsible for the care of the patient. | |||
|M | |||
| | |||
|- | |||
|END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) | |||
|The end date of an assignment of a Care Professional responsible for the care of the patient. | |||
|R | |||
| | |||
|- | |||
|TREATMENT FUNCTION CODE (MENTAL HEALTH) | |||
|'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest. | |||
|R | |||
|319 Respite Care Service | |||
348 Post-COVID-19 Syndrome Service | |||
656 Clinical Psychology Service | |||
700 Learning Disability Service | |||
710 Adult Mental Health Service | |||
711 Child and Adolescent Psychiatry Service | |||
712 Forensic Psychiatry Service | |||
713 Medical Psychotherapy Service | |||
715 Old Age Psychiatry Service | |||
720 Eating Disorders Service | |||
721 Addiction Service | |||
722 Liaison Psychiatry Service | |||
723 Psychiatric Intensive Care Service | |||
724 Perinatal Mental Health Service | |||
725 Mental Health Recovery and Rehabilitation Service | |||
726 Mental Health Dual Diagnosis Service | |||
727 Dementia Assessment Service | |||
730 Neuropsychiatry Service | |||
|}<br /> | |||
=== Mental Health Delayed Discharge === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) | |||
|The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place. | |||
|M | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) | |||
|The date that a period of delayed discharge for a patient who had previously been ready for discharge ended. This may end because the patient was discharged or because the patient was no longer ready for discharge. | |||
|R | |||
| | |||
|- | |||
|MENTAL HEALTH DELAYED DISCHARGE REASON | |||
|The reason that a patient was not able to be discharged despite being medically ready for discharge. | |||
|R | |||
|A2 - Awaiting care coordinator allocation | |||
B1 - Awaiting public funding | |||
C1 - Awaiting further non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc) | |||
D1 - Awaiting Care Home Without Nursing placement or availability | |||
D2 - Awaiting Care Home With Nursing placement or availability | |||
E1 - Awaiting care package in own home | |||
F2 - Awaiting community equipment, telecare and/or adaptations | |||
G2 - Patient or Family choice (reason not stated by patient or family) | |||
G3 - Patient or Family choice - Non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc) | |||
G4 - Patient or Family choice - Care Home Without Nursing placement | |||
G5 - Patient or Family choice - Care Home With Nursing placement | |||
G6 - Patient or Family choice - Care package in own home | |||
G7 - Patient or Family choice - Community equipment, telecare and/or adaptations | |||
G8 - Patient or Family Choice - general needs housing/private landlord acceptance as patient NOT covered by Housing Act/Care Act | |||
G9 - Patient or Family choice - Supported accommodation | |||
G10 - Patient or Family choice - Emergency accommodation from the Local Authority under the Housing Act | |||
G11 - Patient or Family choice - Child or young person awaiting social care or family placement | |||
G12 - Patient or Family choice - Ministry of Justice agreement/permission of proposed placement | |||
H1 - Disputes | |||
I2 - Housing - Awaiting availability of general needs housing/private landlord accommodation acceptance as patient NOT covered by Housing Act and/or Care Act | |||
I3 - Housing - Single homeless patients or asylum seekers NOT covered by Care Act | |||
J2 - Housing - Awaiting supported accommodation | |||
K2 - Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act | |||
L1 - Child or young person awaiting social care or family placement | |||
M1 - Awaiting Ministry of Justice agreement/permission of proposed placement | |||
N1 - Awaiting outcome of legal requirements (mental capacity/mental health legislation) | |||
P1 - Awaiting residential special school or college placement or availability | |||
Q1 - Lack of local education support | |||
R1 - Public safety concern unrelated to clinical treatment need (care team) | |||
R2 - Public safety concern unrelated to clinical treatment need (Ministry of Justice) | |||
S1 - No lawful community care package available | |||
T1 - Lack of health care service provision | |||
T2 - Lack of social care support | |||
98 - No reason given | |||
|- | |||
|MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE | |||
|An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable. | |||
|R | |||
|04 - NHS, excluding housing | |||
05 - Social Care, excluding housing | |||
06 - Both (NHS and Social Care), excluding housing | |||
07 - Housing (including supported/specialist housing) | |||
|- | |||
|ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE) | |||
|The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period. | |||
|R | |||
| | |||
|}<br /> | |||
=== Restrictive Intervention Incident === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER | |||
|A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell | |||
|M | |||
| | |||
|- | |||
|START DATE (RESTRICTIVE INTERVENTION INCIDENT) | |||
|The Start Date of the Restrictive Intervention Incident as reported by the Care Professional. | |||
|M | |||
| | |||
|- | |||
|START TIME (RESTRICTIVE INTERVENTION INCIDENT) | |||
|The Start Time of the Restrictive Intervention Incident as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|END DATE (RESTRICTIVE INTERVENTION INCIDENT) | |||
|The End Date of the Restrictive Intervention Incident as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|END TIME (RESTRICTIVE INTERVENTION INCIDENT) | |||
|The End Time of the Restrictive Intervention Incident as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT) | |||
|An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention. | |||
|R | |||
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention | |||
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention | |||
|- | |||
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT) | |||
|The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention. | |||
|R | |||
|1 - Clinical decision to delay | |||
2 - Patient refused to take part | |||
3 - Other (not listed) | |||
|- | |||
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL) | |||
|An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention. | |||
|R | |||
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention | |||
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention | |||
|- | |||
|RESTRICTIVE INTERVENTION REASON | |||
|The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell. | |||
|R | |||
|10 - Prevent a patient being violent to others | |||
11 - Prevent a patient causing serious intentional harm to themselves | |||
12 - Prevent a patient causing serious physical injury to themselves by accident | |||
13 - Lawfully administer medicines or other medical treatment | |||
14 - Facilitate personal care | |||
15 - Facilitate nasogastric (NG) feeding | |||
16 - Prevent the patient exhibiting extreme and prolonged over-activity | |||
17 - Prevent the PATIENT exhibiting otherwise dangerous behaviour | |||
18 - Undertake a search of the patient’s clothing or property to ensure the safety of others | |||
19 - Prevent the patient absconding from lawful custody | |||
98 - Other (not listed) | |||
99 - Not Known (Not Recorded) | |||
|}<br /> | |||
=== Restrictive Intervention Type === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|RESTRICTIVE INTERVENTION TYPE IDENTIFIER | |||
|A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell | |||
|M | |||
| | |||
|- | |||
|START DATE (RESTRICTIVE INTERVENTION TYPE) | |||
|The Start Date of the Restrictive Intervention Type as reported by the Care Professional. | |||
|M | |||
| | |||
|- | |||
|START TIME (RESTRICTIVE INTERVENTION TYPE) | |||
|The Start Time of the Restrictive Intervention Type as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|RESTRICTIVE INTERVENTION TYPE | |||
|Type of RESTRICTIVE INTERVENTION used. | |||
|R | |||
|01 - Physical restraint - Prone | |||
07 - Physical restraint - Standing | |||
08 - Physical restraint - Restrictive escort | |||
09 - Physical restraint - Supine | |||
10 - Physical restraint - Side | |||
11 - Physical restraint - Seated | |||
12 - Physical restraint - Kneeling | |||
13 - Physical restraint - Other (not listed) | |||
14 - Chemical restraint - Injection (Rapid Tranquillisation) | |||
15 - Chemical restraint - Injection (Non Rapid Tranquillisation) | |||
16 - Chemical restraint - Oral | |||
17 - Chemical restraint - Other (not listed) | |||
04 - Mechanical restraint | |||
05 - Seclusion | |||
06 - Segregation | |||
|- | |||
|END DATE (RESTRICTIVE INTERVENTION TYPE) | |||
|The End Date of the Restrictive Intervention Type as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|END TIME (RESTRICTIVE INTERVENTION TYPE) | |||
|The End Time of the Restrictive Intervention Type as reported by the Care Professional. | |||
|R | |||
| | |||
|- | |||
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT) | |||
|An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention. | |||
|R | |||
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention | |||
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention | |||
|- | |||
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL) | |||
|An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention. | |||
|R | |||
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention | |||
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention | |||
|- | |||
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON) | |||
|An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention. | |||
|R | |||
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention | |||
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention | |||
|}<br /> | |||
=== Police Assistance Request === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|POLICE ASSISTANCE REQUEST DATE | |||
|The date the call was made to request police assistance | |||
|M | |||
| | |||
|- | |||
|POLICE ASSISTANCE REQUEST TIME | |||
|The time the call was made to request police assistance | |||
|R | |||
| | |||
|- | |||
|POLICE ASSISTANCE ARRIVAL DATE | |||
|The date the Police arrived following the request for assistance | |||
|R | |||
| | |||
|- | |||
|POLICE ASSISTANCE ARRIVAL TIME | |||
|The time the Police arrived following the request for assistance | |||
|R | |||
| | |||
|- | |||
|POLICE RESTRAINT OR FORCE USED INDICATOR | |||
|An indication of whether the police used restraint or force on a PATIENT. | |||
|R | |||
|Y - Yes - the police used restraint or force on a PATIENT | |||
N - No - the police did not use restraint or force on a PATIENT | |||
|}<br /> | |||
=== Assault === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DATE OF ASSAULT ON PATIENT | |||
|The DATE that an instance of assault on the PATIENT by another PATIENT occurred. | |||
|M | |||
| | |||
|}<br /> | |||
=== Self-Harm === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DATE OF SELF-HARM | |||
|The date that an incident of self-harm for the patient occurred. | |||
|M | |||
| | |||
|- | |||
|OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE) | |||
|The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL. | |||
|M | |||
| | |||
|}<br /> | |||
=== Home Leave === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (HOME LEAVE) | |||
|The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. | |||
|M | |||
| | |||
|- | |||
|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 | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (MENTAL HEALTH LEAVE OF ABSENCE) | |||
|The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | |||
|M | |||
| | |||
|- | |||
|START TIME (MENTAL HEALTH LEAVE OF ABSENCE) | |||
|The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | |||
|R | |||
| | |||
|- | |||
|END DATE (MENTAL HEALTH LEAVE OF ABSENCE) | |||
|The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | |||
|R | |||
| | |||
|- | |||
|END TIME (MENTAL HEALTH LEAVE OF ABSENCE) | |||
|The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | |||
|R | |||
| | |||
|- | |||
|MENTAL HEALTH LEAVE OF ABSENCE END REASON | |||
|The reason a Mental Health Leave of Absence ended. | |||
|R | |||
|01 - Patient returned on or before day specified | |||
02 - Leave revoked and patient recalled by Mental Health Responsible Clinician | |||
03 - Period of leave to be extended | |||
04 - Patient failed to return on or before day specified and is absent without leave | |||
05 - Patient's liability for detention terminated by Mental Health Responsible Clinician | |||
06 - Patient's liability for detention terminated by Mental Health Act Review Tribunal | |||
07 - Patient's liability for detention terminated by Hospital Managers | |||
08 - Patient died | |||
96 - Other (not listed) | |||
99 - MENTAL HEALTH LEAVE OF ABSENCE END REASON Not Known (Not Recorded) | |||
|- | |||
|ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR | |||
|An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted. | |||
|R | |||
|Y - Yes - a period of Mental Health Leave of Absence is escorted | |||
N - No - a period of Mental Health Leave of Absence is not escorted | |||
|}<br /> | |||
=== Mental Health Trial Leave === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (MENTAL HEALTH TRIAL LEAVE) | |||
|The Start Date of a period of Mental Health Trial Leave for a PATIENT. | |||
|M | |||
| | |||
|- | |||
|START TIME (MENTAL HEALTH TRIAL LEAVE) | |||
|The Start Time of a period of Mental Health Trial Leave for a PATIENT. | |||
|R | |||
| | |||
|- | |||
|END TIME (MENTAL HEALTH TRIAL LEAVE) | |||
|The End Time of a period of Mental Health Trial Leave for a PATIENT. | |||
|R | |||
| | |||
|}<br /> | |||
=== Hospital Provider Spell Commissioner Assignment Period === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (COMMISSIONER ASSIGNMENT PERIOD) | |||
|The Start Date of the Commissioner Assignment Period. | |||
|M | |||
| | |||
|- | |||
|END DATE (COMMISSIONER ASSIGNMENT PERIOD) | |||
|The End Date of the Commissioner Assignment Period. | |||
|R | |||
| | |||
|}<br /> | |||
=== Specialised Mental Health Exceptional Package of Care === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE | |||
|The amount charged for the SMH EPC in the reporting period | |||
|M | |||
| | |||
|- | |||
|START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) | |||
|The start date of an SMH EPC. | |||
|M | |||
| | |||
|- | |||
|END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) | |||
|The End Date of an SMH EPC. | |||
|R | |||
| | |||
|}<br /> | |||
=== Medical History (Previous Diagnosis) === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DIAGNOSIS SCHEME IN USE (MENTAL HEALTH) | |||
|The code scheme basis of the Diagnosis. | |||
|M | |||
|02 - ICD-10 | |||
06 - SNOMED CT® | |||
|- | |||
|PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) | |||
|A unique identifier for a clinical diagnosis from a specific classification or clinical terminology. | |||
|M | |||
| | |||
|- | |||
|CODED DIAGNOSIS TIMESTAMP | |||
|The date, time and time zone for the PATIENT DIAGNOSIS. | |||
|R | |||
| | |||
|}<br /> | |||
=== Provisional Diagnosis === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) | |||
|This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare. | |||
|M | |||
| | |||
|}<br /> | |||
=== Primary Diagnosis === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) | |||
|This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem. | |||
|M | |||
| | |||
|} | |||
<br /> | |||
=== Secondary Diagnosis === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) | |||
|This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded. | |||
|M | |||
| | |||
|- | |||
|CODED DIAGNOSIS TIMESTAMP | |||
|The date, time and time zone for the PATIENT DIAGNOSIS. | |||
|R | |||
| | |||
|} | |||
<br /> | |||
=== Coded Scored Assessment (Referral) === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CODED ASSESSMENT TOOL TYPE (SNOMED CT) | |||
|The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT. | |||
|M | |||
| | |||
|- | |||
|PERSON SCORE | |||
|The observable value (score) resulting from an assessment. | |||
|M | |||
| | |||
|- | |||
|ASSESSMENT TOOL COMPLETION TIMESTAMP | |||
|The date, time and time zone on which the assessment took place | |||
|M | |||
| | |||
|} | |||
<br /> | |||
=== Care Programme Approach (CPA) Care Episode === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER | |||
|A unique identifier allocated to each Care Programme Approach Care Episode. | |||
|M | |||
| | |||
|- | |||
|START DATE (CARE PROGRAMME APPROACH CARE) | |||
|The start date for Care Programme Approach Care for the patient. | |||
|M | |||
| | |||
|- | |||
|END DATE (CARE PROGRAMME APPROACH CARE) | |||
|The end date for Care Programme Approach Care for the patient. | |||
|R | |||
| | |||
|} | |||
<br /> | |||
=== Care Programme Approach (CPA) Review === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary 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 | |||
!Codes & Primary Value Set | |||
|- | |||
|CLUSTERING TOOL ASSESSMENT IDENTIFIER | |||
|A unique identifier for each clustering tool assessment that takes place for each patient. | |||
|M | |||
| | |||
|- | |||
|CLUSTERING TOOL ASSESSMENT CATEGORY | |||
|The category of the clustering tool assessment completed. | |||
|M | |||
|01 - Adult Mental Health Clustering Tool | |||
03 - Learning Disabilities Clustering Tool | |||
04 - Forensic Mental Health Clustering Tool | |||
05 - Forensic Learning Disabilities Clustering Tool | |||
06 - Child and Adolescent Mental Health Needs Based Grouping Tool | |||
|- | |||
|ASSESSMENT TOOL COMPLETION DATE | |||
|The date on which a clustering tool assessment was completed for a patient. | |||
|M | |||
| | |||
|- | |||
|ASSESSMENT TOOL COMPLETION TIME | |||
|The time on which a clustering tool assessment was completed for a patient. | |||
|R | |||
| | |||
|- | |||
|CLUSTERING TOOL ASSESSMENT REASON | |||
|The reason that the clustering tool assessment for the patient was undertaken. | |||
|R | |||
|10 - Initial assessment | |||
11 - Scheduled re-assessment | |||
12 - Re-assessment following significant unanticipated change in need | |||
97 - Other Reason (not listed) | |||
99 - CLUSTERING TOOL ASSESSMENT REASON Not Known (Not Recorded) | |||
|- | |||
|MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE | |||
|The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation. | |||
|R | |||
|A - Non-Psychotic | |||
B - Psychotic | |||
C - Organic | |||
Z - Unable to assign patient to Mental Health Care Cluster Super Class | |||
|- | |||
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) | |||
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm. | |||
|R | |||
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE) | |||
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity) | |||
02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need) | |||
03 - Care Cluster 3 - Non-Psychotic (Moderate Severity) | |||
04 - Care Cluster 4 - Non-Psychotic (Severe) | |||
05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe) | |||
06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas | |||
07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability) | |||
08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders | |||
09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used. | |||
10 - Care Cluster 10 - First Episode Psychosis | |||
11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms) | |||
12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability) | |||
13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability) | |||
14 - Care Cluster 14 - Psychotic Crisis | |||
15 - Care Cluster 15 - Severe Psychotic Depression | |||
16 - Care Cluster 16 - Dual Diagnosis | |||
17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage) | |||
18 - Care Cluster 18 - Cognitive Impairment (Low Need) | |||
19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need) | |||
20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need) | |||
21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement) | |||
|- | |||
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) | |||
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|- | |||
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) | |||
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|} | |||
<br /> | |||
=== Care Cluster === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (CARE CLUSTER ASSIGNMENT PERIOD) | |||
|The date on which the assignment of a patient to a Care Cluster started. | |||
|M | |||
| | |||
|- | |||
|START TIME (CARE CLUSTER ASSIGNMENT PERIOD) | |||
|The time on which the assignment of a patient to a Care Cluster started. | |||
|R | |||
| | |||
|- | |||
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) | |||
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm. | |||
|R | |||
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE) | |||
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity) | |||
02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need) | |||
03 - Care Cluster 3 - Non-Psychotic (Moderate Severity) | |||
04 - Care Cluster 4 - Non-Psychotic (Severe) | |||
05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe) | |||
06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas | |||
07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability) | |||
08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders | |||
09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used. | |||
10 - Care Cluster 10 - First Episode Psychosis | |||
11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms) | |||
12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability) | |||
13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability) | |||
14 - Care Cluster 14 - Psychotic Crisis | |||
15 - Care Cluster 15 - Severe Psychotic Depression | |||
16 - Care Cluster 16 - Dual Diagnosis | |||
17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage) | |||
18 - Care Cluster 18 - Cognitive Impairment (Low Need) | |||
19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need) | |||
20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need) | |||
21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement) | |||
|- | |||
|CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE | |||
|The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL. | |||
|R | |||
|10 - Getting Advice: Neurodevelopmental Assessment (NEU) | |||
11 - Getting Advice: Signposting and Self-management Advice (ADV) | |||
12 - Getting Help: Attention Deficit Hyperactivity Disorder (ADHD) | |||
13 - Getting Help: Autism (AUT) | |||
14 - Getting Help: Behavioural and/or Conduct Disorders (BEH) | |||
15 - Getting Help: Bipolar Disorder (BIP) | |||
16 - Getting Help: Depression (DEP) | |||
17 - Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP) | |||
18 - Getting Help: Obsessive compulsive disorder (OCD) | |||
19 - Getting Help: Post-traumatic stress disorder (PTS) | |||
20 - Getting Help: Self-harm (SHA) | |||
21 - Getting Help: Social Anxiety Disorder (SOC) | |||
22 - Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM) | |||
23 - Getting Help: Co-occurring Emotional Difficulties (EMO) | |||
24 - Getting Help: Difficulties Not Covered by Other Groupings (DNC) | |||
25 - Getting More Help: Eating Disorders (EAT) | |||
26 - Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP) | |||
27 - Getting More Help: Psychosis (PSY) | |||
28 - Getting More Help: Difficulties of Severe Impact (DSI) | |||
|- | |||
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) | |||
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|- | |||
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) | |||
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. | |||
|R | |||
|00 - Care Cluster 0: Variance | |||
01 - Care Cluster 1: Common Mental Health Problems (Low Severity) | |||
02 - Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need) | |||
03 - Care Cluster 3: Non-Psychotic (Moderate Severity) | |||
04 - Care Cluster 4: Non-Psychotic (Severe) | |||
05 - Care Cluster 5: Non-Psychotic Disorders (Very Severe) | |||
06 - Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas | |||
07 - Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability) | |||
08 - Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders | |||
08b - Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders | |||
10 - Care Cluster 10: First Episode Psychosis | |||
11 - Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms) | |||
12 - Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability) | |||
13 - Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability) | |||
14 - Care Cluster 14: Psychotic Crisis | |||
15 - Care Cluster 15: Severe Psychotic Depression | |||
16 - Care Cluster 16: Dual Diagnosis | |||
17 - Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage) | |||
18 - Care Cluster 18: Cognitive Impairment (Low Need) | |||
19 - Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need) | |||
20 - Care Cluster 20: Cognitive Impairment or Dementia (High Need) | |||
21 - Care Cluster 21: Cognitive Impairment or Dementia (High Physical or Engagement) | |||
|- | |||
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) | |||
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | |||
|P | |||
| | |||
|- | |||
|END DATE (CARE CLUSTER ASSIGNMENT PERIOD) | |||
|The date on which the assignment of a patient to a Care Cluster ended. | |||
|R | |||
| | |||
|- | |||
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD) | |||
|The time on which the assignment of a patient to a Care Cluster ended. | |||
|R | |||
| | |||
|} | |||
<br /> | |||
=== Five Forensic Pathways === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|FIVE FORENSIC PATHWAYS ASSESSMENT DATE | |||
|The date on which a Five Forensic Pathways assessment was completed for a patient. | |||
|M | |||
| | |||
|- | |||
|FIVE FORENSIC PATHWAYS ASSESSMENT REASON | |||
|The reason for which a Five Forensic Pathways assessment was undertaken. | |||
|R | |||
|10 - Initial Assessment | |||
11 - Scheduled Re-Assessment | |||
12 - Re-Assessment following significant unanticipated change in need | |||
97 - Other Reason (not listed) | |||
99 - Not Known (Not Recorded) | |||
|- | |||
|FIVE FORENSIC PATHWAYS CODE | |||
|The Five Forensic Pathway assigned to a patient. | |||
|M | |||
|0 - Unable to assign patient to one of the five forensic pathways | |||
1 - Treatment responsive group | |||
2 - Treatment resistant group – challenging behaviour | |||
3 - Treatment resistant group – continuing care | |||
4 - Personality disorder group – prison transfer | |||
5 - Personality disorder group – co-morbidity | |||
|} | |||
<br /> | |||
=== Care Professionals === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PROFESSIONAL REGISTRATION BODY CODE | |||
|A code which identifies the PROFESSIONAL REGISTRATION BODY. | |||
|R | |||
|01 - General Chiropractic Council | |||
02 - General Dental Council | |||
03 - General Medical Council | |||
04 - General Optical Council | |||
05 - Social Care Wales | |||
08 - Health and Care Professions Council | |||
09 - Nursing and Midwifery Council | |||
16 - General Pharmaceutical Council | |||
17 - General Osteopathic Council | |||
18 - Social Work England | |||
|- | |||
|PROFESSIONAL REGISTRATION ENTRY IDENTIFIER | |||
|The registration identifier allocated by an ORGANISATION. | |||
|R | |||
| | |||
|- | |||
|CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) | |||
|The staff group of a CARE PROFESSIONAL working in a Mental Health Service. | |||
|R | |||
|01 - Medical | |||
02 - Nursing | |||
03 - Psychology | |||
04 - Primary Mental Health | |||
05 - Child and Adolescent Psychotherapy | |||
06 - Counselling | |||
07 - Family and Systemic Psychotherapy | |||
08 - Occupational Therapy | |||
09 - Social Work | |||
10 - Creative Therapy | |||
11 - Other Therapy (Qualified) | |||
12 - Education | |||
13 - Speech and Language Therapy | |||
97 - Other (Qualified) | |||
98 - Other (Unqualified) | |||
|- | |||
|MAIN SPECIALTY CODE (MENTAL HEALTH) | |||
|The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period. | |||
|R | |||
|600 - General Medical Practice | |||
700 - Learning Disability | |||
710 - Adult Mental illness | |||
711 - Child and Adolescent Psychiatry | |||
712 - Forensic Psychiatry | |||
713 - Medical Psychotherapy | |||
715 - Old age psychiatry | |||
950 - Nursing | |||
960 - Allied Health Professional | |||
|- | |||
|OCCUPATION CODE | |||
|An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual. | |||
|R | |||
| | |||
|- | |||
|CARE PROFESSIONAL (JOB ROLE CODE) | |||
|A National Code for a POSITION applicable to an EMPLOYEE. | |||
|R | |||
| | |||
|}<br /> | |||
== IAPT == | |||
<br /> | |||
=== Data Linkage === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE PERSONNEL LOCAL IDENTIFIER | |||
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system. | |||
|M | |||
| | |||
|} | |||
=== Header === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DATA SET VERSION NUMBER | |||
|The version of the data set that this submission file is for. | |||
|M | |||
| | |||
|- | |||
|ORGANISATION IDENTIFIER (CODE OF PROVIDER) | |||
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database | |||
|M | |||
| | |||
|- | |||
|ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) | |||
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation. | |||
|M | |||
| | |||
|- | |||
|PRIMARY DATA COLLECTION SYSTEM IN USE | |||
|The name of the Primary Data Collection System in use by the Health Care Provider. | |||
|M | |||
| | |||
|- | |||
|REPORTING PERIOD START DATE | |||
|The reporting period start date to which this file refers | |||
|M | |||
| | |||
|- | |||
|REPORTING PERIOD END DATE | |||
|The reporting period end date to which this file refers | |||
|M | |||
| | |||
|- | |||
|DATE AND TIME DATE SET CREATED | |||
|Date/time this upload file was created | |||
|M | |||
| | |||
|} | |||
=== MPI === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|The type of Educational Establishment that the student is attending. | |||
|R | |||
|1 - School | |||
2 - College | |||
3 - University | |||
4 - Other Educational Establishment not listed | |||
8 - Not applicable (Patient is not a student) | |||
Z - Not stated (Patient asked but declined to provide a response) | |||
X - Not Known (Not Recorded) | |||
|} | |||
=== Employment Status === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SELF EMPLOYED INDICATOR | |||
|'An indication of whether an employed person is self-employed. | |||
|R | |||
|Y - Yes - Employed as a self-employed worker | |||
N - No - Not self employed | |||
8 - Not Applicable (Person is unemployed) | |||
Z - Not stated (Person asked but declined to provide a response) | |||
|- | |||
|SICKNESS ABSENCE INDICATOR | |||
|'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness. | |||
|R | |||
|Y - Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness | |||
N - No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness | |||
8 - Not Applicable (The person is unemployed) | |||
Z - Not stated (Person asked but declined to provide a response) | |||
X - Not Known (Not Recorded) | |||
|- | |||
|STATUTORY SICK PAY RECEIPT INDICATOR | |||
|'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON. | |||
|R | |||
|Y - Yes - the person is currently in receipt of Statutory Sick Pay | |||
N - No - the person is currently not in receipt of Statutory Sick Pay | |||
U - Unknown (Person asked and does not know or is not sure) | |||
Z - Not stated (Person asked but declined to provide a response) | |||
|- | |||
|BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|'An indication of whether a patient is currently receiving benefits, as stated by the patient. | |||
|R | |||
|Y - Yes - the PATIENT is currently in receipt of a benefit | |||
N - No - the PATIENT is not currently in receipt of a benefit | |||
U - Unknown (Person asked and does not know or is not sure) | |||
Z - Not stated (Person asked but declined to provide a response) | |||
|- | |||
|EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR | |||
|'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient. | |||
|R | |||
|Y - Yes - receiving Employment and Support Allowance | |||
N - No - not receiving Employment and Support Allowance | |||
U - Unknown (Patient asked and does not know or is not sure) | |||
Z - Not stated (Patient asked but declined to provide a response) | |||
|- | |||
|UNIVERSAL CREDIT RECEIPT INDICATOR | |||
|'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient. | |||
|R | |||
|Y - Yes - receiving Universal Credit | |||
N - No - not receiving Universal Credit | |||
U - Unknown (Patient asked and does not know or is not sure) | |||
Z - Not stated (Patient asked but declined to provide a response) | |||
|- | |||
|PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR | |||
|'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient. | |||
|R | |||
|Y - Yes - receiving Personal Independence Payment | |||
N - No - Not receiving Personal Independence Payment | |||
U - Unknown (Patient asked and does not know or is not sure) | |||
Z - Not stated (Patient asked but declined to provide a response) | |||
|- | |||
|EMPLOYMENT SUPPORT SUITABILITY INDICATOR | |||
|'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support. | |||
|R | |||
|Y - Yes - the patient is a suitable candidate for referral to Employment Support | |||
N - No - the patient is not a suitable candidate for referral to Employment Support | |||
N/A - Not Applicable | |||
|- | |||
|EMPLOYMENT SUPPORT REFERRAL DATE | |||
|The date the PATIENT was referred for Employment Support. | |||
|R | |||
| | |||
|}<br /> | |||
=== Social & Personal Circumstances === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE | |||
| | |||
|R | |||
| | |||
|}<br /> | |||
=== Referral === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES | |||
|The source of referral to a Mental Health Service. | |||
|R | |||
|A1 - Primary Health Care: General Medical Practitioner Practice | |||
A2 - Primary Health Care: Health Visitor | |||
A3 - Other Primary Health Care | |||
A4 - Primary Health Care: Maternity Service | |||
B1 - Self Referral: Self | |||
B2 - Self Referral: Carer/Relative | |||
C1 - Local Authority and Other Public Services: Social Services | |||
C2 - Local Authority and Other Public Services: Education Service / Educational Establishment | |||
C3 - Local Authority and Other Public Services: Housing Service | |||
D1 - Employer | |||
D2 - Employer: Occupational Health | |||
E1 - Justice System: Police | |||
E2 - Justice System: Courts | |||
E3 - Justice System: Probation Service | |||
E4 - Justice System: Prison | |||
E5 - Justice System: Court Liaison and Diversion Service | |||
E6 - Justice System: Youth Offending Team | |||
F1 - Child Health: School Nurse | |||
F2 - Child Health: Hospital-based Paediatrics | |||
F3 - Child Health: Community-based Paediatrics | |||
G1 - Independent sector - Medium Secure Inpatients | |||
G2 - Independent Sector - Low Secure Inpatients | |||
G3 - Other Independent Sector Mental Health Services | |||
G4 - Voluntary Sector | |||
H1 - Acute Secondary Care: Emergency Care Department | |||
H2 - Other secondary care specialty | |||
I1 - Temporary transfer from another Mental Health NHS Trust | |||
I2 - Permanent transfer from another Mental Health NHS Trust | |||
M1 - Other: Asylum Services | |||
M2 - Other: Telephone or Electronic Access Service | |||
M3 - Other: Out of Area Agency | |||
M4 - Other: Drug Action Team / Drug Misuse Agency | |||
M5 - Other: Jobcentre Plus | |||
M6 - Other SERVICE or agency | |||
M7 - Other: Single Point of Access Service | |||
M8 - Debt agency | |||
N1 - Stepped up from low intensity Improving Access to Psychological Therapies Service | |||
N2 - Stepped down from high intensity Improving Access to Psychological Therapies Service | |||
N4 - Other Improving Access to Psychological Therapies Service | |||
P1 - Internal Referral | |||
Q1 - Mental Health Drop In Service | |||
|- | |||
|YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT. | |||
|R | |||
| | |||
|- | |||
|PREVIOUS DIAGNOSED CONDITION INDICATOR | |||
|An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT. | |||
|R | |||
|Y - Yes - this is a recurrence of a previously diagnosed condition | |||
N - No - this is not a recurrence of a previously diagnosed condition | |||
U - Unknown (Patient asked and does not know or is unsure) | |||
Z - Not stated (Patient asked but declined to provide a response) | |||
|- | |||
|DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON | |||
|The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service. | |||
|R | |||
|'''Referred but not seen''' | |||
50 - Not assessed | |||
'''Seen but not taken on for a course of treatment''' | |||
10 - Not suitable for IAPT service - no action taken or directed back to referrer | |||
11 - Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient | |||
12 - Discharged by mutual agreement following advice and support | |||
13 - Referred to another therapy service by mutual agreement | |||
14 - Suitable for IAPT service, but patient declined treatment that was offered | |||
16 - Incomplete Assessment (Patient dropped out) | |||
17 - Deceased (Seen but not taken on for a course of treatment) | |||
95 - Not Known (Seen but not taken on for a course of treatment) | |||
'''Seen and taken on for a course of treatment''' | |||
46 - Mutually agreed completion of treatment | |||
47 - Termination of treatment earlier than Care Professional planned | |||
48 - Termination of treatment earlier than patient requested | |||
49 - Deceased (Seen and taken on for a course of treatment) | |||
96 - Not Known (Seen and taken on for a course of treatment) | |||
|- | |||
|SERVICE DISCHARGE DATE | |||
|The date a PATIENT was discharged from a SERVICE. | |||
|R | |||
| | |||
|} | |||
=== Onward Referral === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|The reason why the patient was referred from one service to another service, which may be in the same or a different organisation. | |||
|R | |||
|1 - Transfer of Clinical Responsibility | |||
2 - For Opinion Only | |||
3 - For Diagnostic Test Only | |||
4 - New Referral (Non Transfer) | |||
5 - Stepped up from low intensity Improving Access to Psychological Therapies Service | |||
6 - Stepped down from high intensity Improving Access to Psychological Therapies Service | |||
96 - Other (not listed) | |||
98 - Onward Referral Reason Not Applicable | |||
99 - Not Known (Not Recorded) | |||
|} | |||
=== Waiting Time Pauses === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER | |||
|The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION. | |||
|M | |||
| | |||
|- | |||
|ACTIVITY SUSPENSION START DATE | |||
|The date on which the break from the ACTIVITY starts. | |||
|M | |||
| | |||
|- | |||
|ACTIVITY SUSPENSION END DATE | |||
|The date on which the break from the ACTIVITY ends. | |||
|R | |||
| | |||
|- | |||
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON | |||
|The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set. Patient Initiated pause in the waiting period. | |||
|R | |||
|1 - Patient unavailable due to holiday | |||
2 - Patient unavailable due to other health needs | |||
3 - Patient stated not available - other reason (not listed) | |||
|} | |||
=== Care Contact === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR | |||
|An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice. | |||
|R | |||
|Y - Yes - Appointment slot could be reallocated | |||
N - No - Appointment slot could not be reallocated | |||
|- | |||
|INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR | |||
|An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service. | |||
|M | |||
|Y - Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological | |||
Therapies Long Term Condition Service | |||
N - No - the Improving Access to Psychological Therapies Contact was not provided by an Integrated Improving Access to Psychological | |||
Therapies Long Term Condition Service | |||
|- | |||
|APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|The type of Improving Access to Psychological Therapies APPOINTMENT. | |||
|M | |||
|1 - Assessment | |||
2 - Treatment | |||
3 - Assessment and treatment | |||
4 - Review only | |||
5 - Review and treatment | |||
6 - Follow-up appointment after treatment end | |||
10 - Employment Support | |||
98 - Other (not listed) | |||
99 - Not Known (Not Recorded) | |||
|- | |||
|INTERNET ENABLED THERAPY PROGRAMME | |||
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT. | |||
|R | |||
| | |||
|- | |||
|NUMBER OF GROUP THERAPY PARTICIPANTS | |||
|The number of persons who participated in the Group Therapy, excluding the Care Professionals. | |||
|R | |||
| | |||
|- | |||
|NUMBER OF GROUP THERAPY FACILITATORS | |||
|The number of Care Professionals who facilitated the Group Therapy. | |||
|R | |||
| | |||
|- | |||
|PSYCHOTROPIC MEDICATION USAGE INDICATION CODE | |||
|An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT. | |||
|R | |||
|1 - Prescribed but not taking | |||
2 - Prescribed and taking | |||
3 - Not Prescribed | |||
UU - Unknown (Patient asked and does not know or is not sure) | |||
ZZ - Not stated (Patient asked but declined to provide a response) | |||
|- | |||
|LANGUAGE CODE (TREATMENT) | |||
|The language used for the delivery of treatment to the Patient. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions. | |||
|R | |||
|'''All Spoken Languages''' | |||
- ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki> | |||
'''Extensions''' | |||
q1 - Braille (for people who are unable to see) | |||
q2 - American Sign Language | |||
q3 - Australian Sign Language | |||
q4 - British Sign Language | |||
q5 - Makaton (devised for children and adults with a variety of communication and Learning Disabilities) | |||
|- | |||
|INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE | |||
|An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter. | |||
|R | |||
|1 - Yes - Professional interpreter | |||
2 - Yes - Family member or friend | |||
3 - Yes - Another Person | |||
4 - No - Interpreter not required | |||
5 - No - Interpreter was required but did not attend | |||
X - Not Known (Not Recorded) | |||
|} | |||
=== Internet Therapy Log === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) | |||
|The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. | |||
|M | |||
| | |||
|- | |||
|END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) | |||
|The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. | |||
|M | |||
| | |||
|- | |||
|INTERNET ENABLED THERAPY PROGRAMME | |||
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT. | |||
|M | |||
| | |||
|- | |||
|DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME | |||
|The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period. | |||
|M | |||
| | |||
|- | |||
|INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR | |||
|An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy. | |||
|R | |||
|Y - Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy | |||
N - No - an Internet Enabled Therapy Integrated Software Engine was not used as part of Internet Enabled Therapy | |||
|} | |||
=== Medical History Previous Diagnosis === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|DIAGNOSIS DATE | |||
|DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS. | |||
|R | |||
| | |||
|} | |||
=== Long Term Condition === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY) | |||
|The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition. | |||
|M | |||
| | |||
|} | |||
=== Presenting Complaints === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|PRESENTING COMPLAINT (CODED CLINICAL ENTRY) | |||
|The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL | |||
|M | |||
| | |||
|- | |||
|PRESENTING COMPLAINT CODING SIGNIFICANCE | |||
|The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL. | |||
|R | |||
|1 - Primary Presenting Complaint | |||
2 - Secondary Presenting Complaint | |||
|- | |||
|PRESENTING COMPLAINT RECORDED DATE | |||
|The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded. | |||
|R | |||
| | |||
|} | |||
=== Care Cluster === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD) | |||
|The time on which the assignment of a patient to a Care Cluster ended. | |||
|R | |||
| | |||
|} | |||
=== Care Personnel Qualification === | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|CARE PERSONNEL LOCAL IDENTIFIER | |||
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | |||
|M | |||
| | |||
|- | |||
|QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | |||
|The qualification or individual accreditation attained or planned to be attained, by the Care Personnel. | |||
|M | |||
|10 - Curriculum for Psychological Wellbeing Practitioners (PWP) | |||
11 - Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT) | |||
12 - Curriculum for Counselling for Depression (CfD) | |||
13 - Curriculum for Couple Therapy for Depression | |||
(CTfD) / Curriculum for Behavioural Couples | |||
Therapy (BCT) for Depression | |||
14 - Curriculum for Dynamic | |||
Interpersonal Therapy (DIT) for Depression | |||
15 - Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT) | |||
16 - Curriculum for Mindfulness-based Cognitive Therapy (MBCT) | |||
17 - Curriculum for Eye Movement Desensitisation Reprocessing (EMDR) | |||
30 - Curriculum for Employment Advisers | |||
31 - Curriculum for Senior Employment Advisers | |||
|- | |||
|EMPLOYEE QUALIFICATION AWARDED DATE | |||
|The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course. | |||
|R | |||
| | |||
|- | |||
|EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE | |||
|The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying. | |||
|R | |||
| | |||
|} | |||
== Freeform Placeholder == | |||
{| class="wikitable" | |||
!Name | |||
!Description | |||
!Conformance | |||
!Codes & Primary Value Set | |||
|- | |||
|FREEFORM NOTES | |||
|Any related notes deemed useful for inclusion within the DDS | |||
|R | |||
| | | | ||
|} | |} | ||
__FORCETOC__ |
Latest revision as of 11:45, 15 February 2023
MHSDS
Master Patient Index
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
LOCAL PATIENT IDENTIFIER (EXTENDED) | This is a number used to identify a PATIENT uniquely within a Health Care Provider. It may be different from the PATIENT's casenote number and may be assigned automatically by the computer system. LOCAL PATIENT IDENTIFIER (EXTENDED) is used where IT systems have a LOCAL PATIENT IDENTIFIER which is longer than 10 characters and LOCAL PATIENT IDENTIFIER cannot be used for data submission. | M | |
ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER) | The ORGANISATION IDENTIFIER of the organisation that assigned the local patient identifier. | M | |
ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) | ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) is the ORGANISATION IDENTIFIER of the Educational Establishment, including Schools. | R | |
NHS NUMBER | A number used to identify a PATIENT uniquely within the NHS in England and Wales | R | |
NHS NUMBER STATUS INDICATOR CODE (MENTAL HEALTH AND MATERNITY) | The NHS NUMBER STATUS INDICATOR of the PATIENT | R | 01- Number present and verified
02- Number present but not traced 03- Trace required 04- Trace attempted - No match or multiple match found 05- Trace needs to be resolved - (NHS Number or patient detail conflict) 06- Trace in progress 07- Number not present and trace not required |
PERSON BIRTH DATE | The date on which a PERSON was born or is officially deemed to have been born | R | |
POSTCODE OF USUAL ADDRESS | The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence' | R | |
GENDER IDENTITY CODE | The gender identity of a PERSON as stated by the PERSON | R | 1- Male (including trans man)
2- Female (including trans woman) 3- Non-binary 4- Other (not listed) X- Not Known (not recorded) Z- Not Stated (person asked but declined to provide a response) |
GENDER IDENTITY SAME AT BIRTH INDICATOR | An indication of whether the patient's gender identity is the same as their gender assigned at birth. | R | Y- Yes - the person's gender identity is the same as their gender assigned at birth
N- No - the person's gender identity is not the same as their gender assigned at birth X- Not Known (not asked) Z- Not Stated (person asked but declined to provide a response) |
PERSON STATED GENDER CODE | The gender of a PERSON. PERSON STATED GENDER CODE is self declared or inferred by observation for those unable to declare their PERSON STATED GENDER. |
R | 1- Male
2- Female 9- Indeterminate (unable to be classified as either male or female) X- Not Known (PERSON STATED GENDER CODE not recorded) |
PERSON MARITAL STATUS | The legal marital status of a PERSON. | R | S- Single
M- Married/Civil Partner D- Divorced/Person whose Civil Partnership has been dissolved W- Widowed/Surviving Civil Partner P- Separated N- Not disclosed 8- Not applicable 9- Not known |
ETHNIC CATEGORY | The ethnicity of a PERSON, as specified by the PERSON. | R | A- White - British
B- White - Irish C- White - Any other White background D- Mixed - White and Black Caribbean E- Mixed - White and Black African F- Mixed - White and Asian G- Mixed - Any other mixed background H- Asian or Asian British - Indian J- Asian or Asian British - Pakistani K- Asian or Asian British - Bangladeshi L- Asian or Asian British - Any other Asian background M- Black or Black British - Caribbean N- Black or Black British - African P- Black or Black British - Any other Black background R- Other Ethnic Groups - Chinese S- Other Ethnic Groups - Any other ethnic group Z- Not stated 99- Not known |
ETHNIC CATEGORY 2021 | Placeholder data item to accommodate the 2021 census when it goes live | P | |
LANGUAGE CODE (PREFERRED) | LANGUAGE CODE (PREFERRED) is the language the PATIENT prefers to use for communication with a Health Care Provider. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions. | R | All Spoken Languages
ISO 639-1 codes at http://www.loc.gov/standards/iso639-2/php/code_list.php Extensions q1- Braille (for people who are unable to see) q2- American Sign Language q3- Australian Sign Language q4- British Sign Language q5- Makaton (devised for children and adults with a variety of communication and Learning Disabilities) |
PERSON DEATH DATE | The date on which a person died or is officially deemed to have died, as recorded on the death certificate. | R |
GP Practice Registration
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) | The ORGANISATION CODE of the GP Practice that the PATIENT is registered with. | M | |
START DATE (GMP PATIENT REGISTRATION) | Start Date on which the PERSON registered with a General Medical Practitioner Practice. | R | |
END DATE (GMP PATIENT REGISTRATION) | The DATE on which the PERSON ceased to be registered with a General Medical Practitioner Practice. | R |
Accommodation Status
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
ACCOMMODATION TYPE | An indication of the type of accommodation that a PATIENT currently has. This should be based on the PATIENT's main or permanent residence. | M | 01- Owner occupier
02- Tenant - Local Authority/Arms Length Management Organisation/registered social housing provider 03- Tenant - private landlord 04- Living with family 05- Living with friends 06- University or College accommodation 07- Accommodation tied to job (including Armed Forces) 08- Mobile accommodation 09- Care home without nursing 10- Care home with nursing 11- Specialist Housing (with suitable adaptations to meet impairment needs and support to live independently) 12- Rough sleeper 13- Squatting 14- Sofa surfing (sleeps on different friends floor each night) 15- Staying with friends/family as a short term guest 16- Bed and breakfast accommodation to prevent or relieve homelessness 17- Sleeping in a night shelter 18- Hostel to prevent or relieve homelessness 19- Temporary housing to prevent or relieve homelessness 20- Admitted patient settings 21- Criminal justice settings 98- Other (not listed) |
SETTLED ACCOMMODATION INDICATOR | An indication of whether the main/permanent residence of the patient is settled accommodation. | R | Y- Yes - Settled Accommodation
N- No - Non-settled Accommodation Z- Not Stated (PATIENT asked but declined to provide a response) 9- Not known (Not Recorded) |
ACCOMMODATION TYPE RECORDED DATE | The PERSON PROPERTY RECORDED DATE when the ACCOMMODATION TYPE was recorded. | R | |
SECURE CHILDRENS HOME PLACEMENT TYPE | The type of placement for a child or young person accommodated in a Secure Children's Home. | R | 1- Secure welfare placement
2- Youth justice placement |
ACCOMMODATION TYPE START DATE | The date that the patient's accommodation type started. | R | |
ACCOMMODATION TYPE END DATE | The date that the patient's accommodation type ended. | R |
Employment Status
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
EMPLOYMENT STATUS | The current PRIMARY EMPLOYMENT status of a PERSON. | M | 01- Employed
02- Unemployed and actively seeking work 03- Undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training as a student and not working or actively seeking work 04- Long-term sick or disabled, those receiving government sickness and disability benefits 05- Looking after the family or home as a homemaker and not working or actively seeking work 06- Not receiving government sickness and disability benefits and not working or actively seeking work 07- Unpaid voluntary work and not working or actively seeking work 08- Retired ZZ- Not Stated (PERSON asked but declined to provide a response) |
EMPLOYMENT STATUS START DATE | The date that the patient's employment status started. | R | |
EMPLOYMENT STATUS END DATE | The date that the patient's employment status ended. | R | |
EMPLOYMENT STATUS RECORDED DATE | The date that the patient's employment status details were recorded by the healthcare professional. | R | |
WEEKLY HOURS WORKED | The number of hours worked in a typical week. | R | 01- 30+ hours
02- 16-29 hours 03- 5-15 hours 04- 1-4 hours 97- Not Stated (PERSON asked but declined to provide a response) 98- Not applicable (PERSON not employed) 99- Number of hours worked not known |
Patient Indicators
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR | An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing. | R | Y - Yes: PATIENT requires constant care and/or supervision
|
PARENTAL RESPONSIBILITIES INDICATOR | An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT. | R | Y - Yes: PATIENT has parental responsibilities for a child or young person
|
YOUNG CARER INDICATOR | An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling. | R | Y - Yes: PATIENT has a caring role for an ill or disabled parent, Carer or sibling
|
LOOKED AFTER CHILD INDICATOR | An indication of whether a PATIENT is a Looked After Child. | R | Yes - is a Looked After Child
Not Known if the PATIENT is a Looked After Child |
LOOKED AFTER CHILD LEGAL STATUS | The legal status of the Looked After Child. This refers to the Children's Act 1989: see details https://www.legislation.gov.uk/ukpga/1989/41/contents | R | 01 - Section 20 Voluntary Agreement
|
EDUCATIONAL ASSESSMENT OUTCOME | The outcome of an EDUCATIONAL ASSESSMENT. | R | 01 - No Special Education Needs
05 - Subject to Education, Health and Care Plan (EHC) |
CHILD PROTECTION PLAN INDICATION CODE | An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan. | R | 1 - Has never been subject to a Child Protection Plan
2 - Has previously been subject to a Child Protection Plan 3 - Is currently subject to a Child Protection Plan X - Not Known whether the PATIENT is or has ever been the subject of a Child Protection Plan |
EX-BRITISH ARMED FORCES INDICATOR | An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member. | R | 02 - Ex-services member
03 - Not an ex-services member or their dependant 05 - Dependant of an ex-services member UU - Unknown (PATIENT asked and does not know or is not sure) ZZ - Not stated (PATIENT asked but declined to provide a response) |
OFFENCE HISTORY INDICATION CODE | An indication of whether the PATIENT has a history of offences, including index offences (i.e. is recordable, committed in England and Wales, prosecuted by the police and is not a breach of the peace).
This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information. |
R | 1 - No - No offence
2 - Yes - Less serious offence 3 - Yes - Serious offence X - Not Known (Not Recorded) |
PRODROME PSYCHOSIS DATE | Date at which first noticeable change in behaviour or mental state occurred prior to emergence of full-blown psychosis for the patient. There should be a clear deterioration in functioning from previous levels.
Examples include poor attendance/worsening performance at school/work, trouble sleeping, withdrawing from/fighting with friends/family, attenuated psychotic symptoms (increased suspiciousness,/jealously, occasionally hearing name being called when no' ones around, whisperings, slight confusion in thinking etc.). |
R | |
EMERGENT PSYCHOSIS DATE | Date at which there was first clear evidence of a positive psychotic symptom for the patient (i.e. delusion, hallucination, or thought disorder), regardless of its duration.
Such a symptom would be scored 4 or more on the PANSS. |
R | |
MANIFEST PSYCHOSIS DATE | Date at which a positive psychotic symptom has lasted for a week for the patient. This is usually just 7 days after the date of the first psychotic symptom. | R | |
FIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION) | Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service. | R | |
PSYCHOSIS FIRST TREATMENT START DATE | Date the patient first commenced prescribed (not PRN) anti-psychotic medication, following referral into an Early Intervention in Psychosis (EIP) Service, and thereafter was compliant for at least 75% of the time during the subsequent month (using clinical judgement).
Note: For the majority of people this will be the same date as the date of prescription. |
R | |
REASONABLE ADJUSTMENT REQUIRED INDICATOR | An indicator to alert the clinician that this patient may need a reasonable adjustment made | R | Y - Yes - the patient requires a Reasonable Adjustment
N - No - the patient does not require a Reasonable Adjustment |
Mental Health Care Coordinator
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) | The start date of a Mental Health Care Coordinator Assignment Period for a patient. | M | |
CARE PROFESSIONAL LOCAL IDENTIFIER | A unique local CARE PROFESSIONAL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|
R | |
END DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) | The end date of a Mental Health Care Coordinator Assignment Period for a patient. | R | |
CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH) | The type of service or team the Care Professional is associated with. | R | A01 Day Care Service
A02 Crisis Resolution Team/Home Treatment Service A05 Primary Care Mental Health Service A06 Community Mental Health Team - Functional A07 Community Mental Health Team - Organic A08 Assertive Outreach Team A09 Community Rehabilitation Service A10 General Psychiatry Service A11 Psychiatric Liaison Service A12 Psychotherapy Service A13 Psychological Therapy Service (non IAPT) A14 Early Intervention Team for Psychosis A15 Young Onset Dementia Team A16 Personality Disorder Service A17 Memory Services/Clinic/Drop in service A18 Single Point of Access Service A19 24/7 Crisis Response Line A20 Health Based Place Of Safety Service A21 Crisis Café/Safe Haven/Sanctuary Service A22 Walk-in Crisis Assessment Unit Service A23 Psychiatric Decision Unit Service A24 Acute Day Service A25 Crisis House Service B01 Forensic Mental Health Service B02 Forensic Learning Disability Service C01 Autism Service C02 Specialist Perinatal Mental Health Community Service C04 Neurodevelopment Team C05 Paediatric Liaison Service C06 Looked After Children Service C07 Youth Offending Service C08 Acquired Brain Injury Service C10 Community Eating Disorder Service D01 Substance Misuse Team D02 Criminal Justice Liaison and Diversion Service D03 Prison Psychiatric Inreach Service D04 Asylum Service D05 Individual Placement and Support Service D06 Mental Health In Education Service D07 Problem Gambling Service D08 Rough Sleeping Service E01 Community Team for Learning Disabilities E02 Epilepsy/Neurological Service E03 Specialist Parenting Service E04 Enhanced/Intensive Support Service F01 Mental Health Support Team F02 Maternal Mental Health Service F03 Mental Health Services for Deaf people F04 Veterans Complex Treatment Service F05 Enhanced care in care homes teams F06 Mental Health and Wellbeing Hubs Z01 Other Mental Health Service - in scope of National Tariff Payment System Z02 Other Mental Health Service - out of scope of National Tariff Payment System |
DisabilityType
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DISABILITY CODE | The DISABILITY of a PERSON.
This could be where: the PERSON has been diagnosed as disabled or the PERSON considers themself to be disabled. |
M | 01 Behaviour and Emotional
02 Hearing 03 Manual Dexterity 04 Memory or ability to concentrate, learn or understand (Learning Disability) 05 Mobility and Gross Motor 06 Perception of Physical Danger 07 Personal, Self Care and Continence 08 Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc) 09 Sight 10 Speech XX Other (not listed) NN No Disability ZZ Not Stated (Person asked but declined to provide a response) |
DISABILITY IMPACT PERCEPTION | The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months. | R | 01 - Yes – limited a lot
02 - Yes – limited a little 03 - No - not limited 04 - Prefer not to say (Patient asked but declined to provide a response) |
Care Plan Type
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PLAN IDENTIFIER | A unique identifierfor Care Plan. | M | |
CARE PLAN TYPE (MENTAL HEALTH) | The type of Care Plan for the patient, recorded by the service. | M | 10 - Mental Health Care Plan
11 - Urgent and Emergency Mental Health Care Plan 12 - Mental Health Crisis Plan 13 - Positive Behaviour Support Plan 14 - Child or Young Person's Mental Health Transition Plan |
CARE PLAN CREATION DATE | The date that a Care Plan was created for a patient. | M | |
CARE PLAN CREATION TIME | The time that a Care Plan was created for a patient. | R | |
CARE PLAN LAST UPDATED DATE | The date that the Care Plan was last updated for a patient.
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date. |
R | |
CARE PLAN LAST UPDATED TIME | The time that the Care Plan was last updated for a patient.
Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time. |
R | |
CARE PLAN IMPLEMENTATION DATE | The date that the Care Plan was implemented for a patient. | R |
Care Plan Agreement
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
FAMILY INVOLVED IN CARE PLAN INDICATOR | An indication of whether a member of the patient's family is currently involved in the patient's care plan.
This only needs to be captured for inpatients that are in scope of Transforming Care. |
R | Y - Yes - a member of the patient's family is currently involved in the patient's care plan
N - No - a member of the patient's family is not currently involved in the patient's care plan 9 - Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN |
FAMILY NOT INVOLVED IN CARE PLAN REASON | The reason that the patient's family is not currently involved in the patient's care plan.
This only needs to be captured for inpatients that are in scope of Transforming Care. |
R | 01 - At the request of the patient
02 - Access restrictions on the family 03 - No known family 08 - Other (not listed) |
CARE PLAN CONTENT AGREED BY | The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT. | M | Patient or Patient Proxy
Advocate Clinical Service or Team Local Community Support Team Commissioner Family member or carer with parental responsibility Family member or carer without parental responsibility |
CARE PLAN CONTENT AGREED DATE | The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy. | R | 10 - Patient or Patient Proxy
12 - Advocate 13 - Clinical Service or Team 14 - Local Community Support Team 15 - Commissioner 16 - Family member or carer with parental responsibility 17 - Family member or carer without parental responsibility |
CARE PLAN CONTENT AGREED TIME | The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy | R |
Assistive Technology to Support Disability Type
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) | The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on. | M | |
PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY) | The date, time and time zone for the prescription of Assistive Technology. | R |
Social and Personal Circumstances
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) | The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person. | M | |
SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP | The date, time and time zone on which the Social and Personal Circumstance was recorded. | R |
Overseas Visitor Charging Category
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
OVERSEAS VISITOR CHARGING CATEGORY | The charging category relating to an OVERSEAS VISITOR STATUS. | M | A - Standard NHS-funded PATIENT
B - Immigration Health Surcharge payee C - Charge-exempt Overseas Visitor (European Economic Area) D - Chargeable European Economic Area PATIENT E - Charge-exempt Overseas Visitor (non-European Economic Area) F - Chargeable non-European Economic Area PATIENT P - Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY 9 - OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded) |
OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE | The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded. | R | |
OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE | The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until. | R |
Mental Health Currency Model
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT) | The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type. | P | |
START DATE (MENTAL HEALTH RESOURCE GROUP) | When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group | P | |
END DATE (MENTAL HEALTH RESOURCE GROUP) | When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service. | P |
Service or Team Referral
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SERVICE REQUEST IDENTIFIER | The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned. | M | |
ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) | This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care. | M | |
REFERRAL REQUEST RECEIVED DATE | This is the date the REFERRAL REQUEST was received by the Health Care Provider. | M | |
REFERRAL REQUEST RECEIVED TIME | This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care. | R | |
NHS SERVICE AGREEMENT LINE NUMBER | A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES. | R | |
SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE | The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements. | R | |
SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET | The source of referral to a Mental Health Service. | R | A1 - Primary Health Care: General Medical Practitioner Practice
A2 - Primary Health Care: Health Visitor A3 - Other Primary Health Care A4 - Primary Health Care: Maternity Service B1 - Self-Referral: Self B2 - Self-Referral: Carer/Relative C1 - Local Authority and Other Public Services: Social Services C2 - Local Authority and Other Public Services: Education Service / Educational Establishment C3 - Local Authority and Other Public Services: Housing Service D1 - Employer D2 - Employer: Occupational Health E1 - Justice System: Police E2 - Justice System: Courts E3 - Justice System: Probation Service E4 - Justice System: Prison E5 - Justice System: Court Liaison and Diversion Service E6 - Justice System: Youth Offending Team F1 - Child Health: School Nurse F2 - Child Health: Hospital-based Paediatrics F3 - Child Health: Community-based Paediatrics G1 - Independent sector - Medium Secure Inpatients G2 - Independent Sector - Low Secure Inpatients G3 - Other Independent Sector Mental Health Services G4 - Voluntary Sector H1 - Acute Secondary Care: Emergency Care Department H2 - Other secondary care specialty I1 - Temporary transfer from another Mental Health NHS Trust I2 - Permanent transfer from another Mental Health NHS Trust M1 - Other: Asylum Services M2 - Other: Telephone or Electronic Access Service M3 - Other: Out of Area Agency M4 - Other: Drug Action Team / Drug Misuse Agency M5 - Other: Jobcentre Plus M6 - Other SERVICE or agency M7 - Other: Single Point of Access Service M9 - Other: Urgent and Emergency Care Ambulance Service N3 - Improving Access to Psychological Therapies Service P1 - Internal Referral Q1 - Mental Health Drop In Service |
ORGANISATION IDENTIFIER (REFERRING) | The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust. | R | |
REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) | The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer. | R | A01 Art Therapist
A02 Clinical Psychologist A03 Dietitian A04 Dramatherapist A05 Music Therapist A06 Occupational Therapist A07 Orthotist A08 Physiotherapist A09 Podiatrist A10 Prosthetist A11 Psychotherapist A12 Radiographer A13 Speech and Language Therapist A14 Orthoptist M01 Community Dentist M02 Consultant M03 General Medical Practitioner M04 General Practitioner with an Extended Role (GPwER) N01 Midwife N02 District Nurse N03 Health Visitor N04 Macmillan Nurse N05 School Nurse N06 Specialist Nursing - Active Case Management (Community Matrons) N07 Specialist Nursing - Arthritis Nursing/Liaison N08 Specialist Nursing - Asthma and Respiratory Nursing/Liaison N09 Specialist Nursing - Breast Care Nursing/Liaison N10 Specialist Nursing - Cancer Related N11 Specialist Nursing - Cardiac Nursing/Liaison N12 Specialist Nursing - Children's Services N13 Specialist Nursing - Community Cystic Fibrosis N14 Specialist Nursing - Continence Services N15 Specialist Nursing - Diabetic Nursing/Liaison N16 Specialist Nursing - Enteral Feeding Nursing Services N17 Specialist Nursing - Haemophilia Nursing Services N19 Specialist Nursing - Infectious Diseases N20 Specialist Nursing - Intensive Care Nursing N21 Specialist Nursing - Palliative/Respite Care N22 Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison N23 Specialist Nursing - Rehabilitation Nursing N24 Specialist Nursing - Stoma Care Services N25 Specialist Nursing - Tissue Viability Nursing/Liaison N26 Specialist Nursing - Transplantation Patients Nursing Services N27 Specialist Nursing - Treatment Room Nursing Services N28 Specialist Nursing - Tuberculosis Specialist Nursing N29 Specialist Nursing - Other Specialist Nursing N30 Specialist Nursing - Safeguarding N31 Practice Nursing N32 Staff Nurse N33 Other Registered Nurse N34 Public Health Nurse C01 Appliances Technician C02 Audiologist C03 Counsellor C04 Nursery Nurse C06 Play Therapist C07 Social Worker C08 Voluntary Care Worker C09 Screener (in a National Screening Programme) C99 Other Care Professional (not listed) |
CLINICAL RESPONSE PRIORITY TYPE | The clinical response priority of a SERVICE REQUEST. | R | 1 - Emergency
2 - Urgent/Serious 3 - Routine 4 - Very Urgent |
PRIMARY REASON FOR REFERRAL (MENTAL HEALTH) | This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service | R | 01 - (Suspected) First Episode Psychosis
02 - Ongoing or Recurrent Psychosis 03 - Bi polar disorder 04 - Depression 05 - Anxiety 06 - Obsessive compulsive disorder 07 - Phobias 08 - Organic brain disorder 09 - Drug and alcohol difficulties 10 - Unexplained physical symptoms 11 - Post-traumatic stress disorder 12 - Eating disorders 13 - Perinatal mental health issues 14 - Personality disorders 15 - Self harm behaviours 16 - Conduct disorders 18 - In crisis 19 - Relationship difficulties 20 - Gender Discomfort issues 21 - Attachment difficulties 22 - Self - care issues 23 - Adjustment to health issues 24 - Neurodevelopmental Conditions, excluding Autism 25 - Suspected Autism 26 - Diagnosed Autism 27 - Preconception perinatal mental health concern 28 - Gambling disorder 29 - Community Perinatal Mental Health Partner Assessment 30 - Behaviours that challenge due to a Learning Disability |
REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH) | The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES. | R | 10 - Unavailability of bed at referring organisation
11 - Safeguarding 12 - Offending restrictions 13 - Staff member or family/friend within the referring organisation 14 - Patient choice 15 - Patient away from home 99 - Not Known (Not Recorded) |
DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT) | The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient | R | |
DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT) | The time that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient | R | |
DISCHARGE PLAN CREATION DATE | The date that a Discharge Plan was created for a patient. | R | |
DISCHARGE PLAN CREATION TIME | The time that a Discharge Plan was created for a patient. | R | |
DISCHARGE PLAN LAST UPDATED DATE | The date that the Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Date. | R | |
DISCHARGE PLAN LAST UPDATED TIME | The time that a Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Time. | R | |
SERVICE DISCHARGE DATE | Service Discharge Date is the date a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral. | R | |
SERVICE DISCHARGE TIME | Service Discharge Time is the time a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral. | R |
Other Reason for Referral
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
OTHER REASON FOR REFERRAL (MENTAL HEALTH) | The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service. | M | 1 - (Suspected) First Episode Psychosis
2 - Ongoing or Recurrent Psychosis 3 - Bi polar disorder 4 - Depression 5 - Anxiety 6 - Obsessive compulsive disorder 7 - Phobias 8 - Organic brain disorder 9 - Drug and alcohol difficulties 10 - Unexplained physical symptoms 11 - Post-traumatic stress disorder 12 - Eating disorders 13 - Perinatal mental health issues 14 - Personality disorders 15 - Self harm behaviours 16 - Conduct disorders 18 - In crisis 19 - Relationship difficulties 20 - Gender Discomfort issues 21 - Attachment difficulties 22 - Self - care issues 23 - Adjustment to health issues 24 - Neurodevelopmental Conditions, excluding Autism 25 - Suspected Autism 26 - Diagnosed Autism 27 - Preconception perinatal mental health concern 28 - Gambling disorder 29 - Community Perinatal Mental Health Partner Assessment 30 - Behaviours that challenge due to a Learning Disability |
Service or Team Type Referred To
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PROFESSIONAL TEAM LOCAL IDENTIFIER | A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | R | |
SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) | The type of service or team within a Mental Health Service that a patient was referred to | M | A01 Day Care Service
A02 Crisis Resolution Team/Home Treatment Service A05 Primary Care Mental Health Service A06 Community Mental Health Team - Functional A07 Community Mental Health Team - Organic A08 Assertive Outreach Team A09 Community Rehabilitation Service A10 General Psychiatry Service A11 Psychiatric Liaison Service A12 Psychotherapy Service A13 Psychological Therapy Service (non IAPT) A14 Early Intervention Team for Psychosis A15 Young Onset Dementia Team A16 Personality Disorder Service A17 Memory Services/Clinic/Drop in service A18 Single Point of Access Service A19 24/7 Crisis Response Line A20 Health Based Place Of Safety Service A21 Crisis Café/Safe Haven/Sanctuary Service A22 Walk-in Crisis Assessment Unit Service A23 Psychiatric Decision Unit Service A24 Acute Day Service A25 Crisis House Service B01 Forensic Mental Health Service B02 Forensic Learning Disability Service C01 Autism Service C02 Specialist Perinatal Mental Health Community Service C04 Neurodevelopment Team C05 Paediatric Liaison Service C06 Looked After Children Service C07 Youth Offending Service C08 Acquired Brain Injury Service C10 Community Eating Disorder Service D01 Substance Misuse Team D02 Criminal Justice Liaison and Diversion Service D03 Prison Psychiatric Inreach Service D04 Asylum Service D05 Individual Placement and Support Service D06 Mental Health In Education Service D07 Problem Gambling Service D08 Rough Sleeping Service E01 Community Team for Learning Disabilities E02 Epilepsy/Neurological Service E03 Specialist Parenting Service E04 Enhanced/Intensive Support Service F01 Mental Health Support Team F02 Maternal Mental Health Service F03 Mental Health Services for Deaf people F04 Veterans Complex Treatment Service F05 Enhanced care in care homes teams F06 Mental Health and Wellbeing Hubs Z01 Other Mental Health Service - in scope of National Tariff Payment System Z02 Other Mental Health Service - out of scope of National Tariff Payment System |
REFERRAL CLOSURE DATE | The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | R | |
REFERRAL CLOSURE TIME | The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | R | |
REFERRAL REJECTION DATE | The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | R | |
REFERRAL REJECTION TIME | The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient. | R | |
REFERRAL CLOSURE REASON | The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set. | R | 01 - Admitted elsewhere (at the same or other Health Care Provider)
02 - Treatment completed 03 - Moved out of the area 04 - No further treatment appropriate 05 - Patient did not attend 06 - Patient died 07 - Patient requested discharge 08 - Referred to other specialty/Service (at the same or other Health Care Provider) 09 - PATIENT refused to be seen |
REFERRAL REJECTION REASON | The reason that a Referral Request has been rejected by the SERVICE. | R | 01 - Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider)
02 - Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider) 03 - Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST) |
Referral to Treatment (RTT)
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PATIENT PATHWAY IDENTIFIER | An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY. | R | |
ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) | This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER. | R | |
WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH) | The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy. | M | 02 - Allied Health Professional Referral To Treatment Measurement
09 - Other Referral To Treatment Measurement Type (not listed) |
REFERRAL TO TREATMENT PERIOD START DATE | The start date of a REFERRAL TO TREATMENT PERIOD. | R | |
REFERRAL TO TREATMENT PERIOD END DATE | The end date of a REFERRAL TO TREATMENT PERIOD. | R | |
REFERRAL TO TREATMENT PERIOD STATUS | The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL. | R | 10 - First activity in a Referral to Treatment Period
11 - First activity at the start of a new Referral to Treatment Period following Active Monitoring 12 - First activity at the start of a new Referral to Treatment Period following a decision to refer directly to the consultant or NHS Allied Health Professional Service (Referral To Treatment Measurement) for a separate condition 20 - Subsequent activity during a Referral to Treatment Period - further activities anticipated 21 - Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated 30 - End of the Referral to Treatment Period: Start of First Definitive Treatment 31 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient 32 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional 33 - End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral 34 - End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required 35 - End of the Referral to Treatment Period: patient declined offered treatment 36 - End of the Referral to Treatment Period: patient died before treatment 90 - Not part of a Referral to Treatment Period: After treatment - First Definitive Treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment) 91 - Not part of a Referral to Treatment Period: Care activity during Active Monitoring 92 - Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral 98 - Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods 99 - Referral to Treatment Period status not yet known |
Onward Referral
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DECISION TO REFER DATE (ONWARD REFERRAL) | DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. | R | |
DECISION TO REFER TIME (ONWARD REFERRAL) | DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION. | R | |
ONWARD REFERRAL DATE | The date the patient was referred to another service, which may be in the same or a different organisation. | M | |
ONWARD REFERRAL TIME | The time the patient was referred to another service, which may be in the same or a different organisation. | R | |
ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET) | The reason why the PATIENT was referred to another service, which may be in the same or a different organisation. | R | 01 - Transfer of Clinical Responsibility
02 - For Opinion Only 03 - For Diagnostic Test Only 04 - New Referral (Non Transfer) 96 - Other (not listed) 98 - Onward Referral Reason Not Applicable 99 - Not Known (Not Recorded) |
REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH) | The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy. | R | 10 - Unavailability of bed at referring organisation
11 - Safeguarding 12 - Offending restrictions 13 - Staff member or family/friend within the referring organisation 14 - Patient choice 99 - Not Known (Not Recorded) |
ORGANISATION IDENTIFIER (RECEIVING) | ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider. | R | |
CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed. | R |
Discharge Plan Agreement
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DISCHARGE PLAN CONTENT AGREED BY | The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT. | M | 10 - Patient or Patient Proxy
12 - Advocate 13 - Clinical Service or Team 14 - Local Community Support Team 15 - Current Commissioner 16 - Commissioner of Planned Discharge Destination 17 - Family member or carer with parental responsibility 18 - Family member or carer without parental responsibility |
DISCHARGE PLAN CONTENT AGREED DATE | The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. | R | |
DISCHARGE PLAN CONTENT AGREED TIME | RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy. | R |
Medication Prescription
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PRESCRIPTION IDENTIFIER | The unique identifier of a PRESCRIPTION. | P | |
PRESCRIPTION DATE (MEDICATION) | The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. | P | |
PRESCRIPTION TIME (MEDICATION) | The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL. | P |
Care Contact
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE CONTACT IDENTIFIER | The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned. | M | |
CARE PROFESSIONAL TEAM LOCAL IDENTIFIER | A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | R | |
CARE CONTACT DATE | The date on which a Care Contact took place, or, if cancelled, was scheduled to take place. | M | |
CARE CONTACT TIME | The time at which a Care Contact took place. | R | |
ADMINISTRATIVE CATEGORY CODE | This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed. | R | 01 - NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)
02 - Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006 03 - Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006 04 - Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff. 98 - Not applicable 99 - ADMINISTRATIVE CATEGORY CODE not known |
CLINICAL CONTACT DURATION OF CARE CONTACT | The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes. | R | |
CONSULTATION TYPE | The type of consultation between the CARE PROFESSIONAL and the PATIENT. | R | 01 - Initial Consultation
02 - Follow-up Consultation |
CARE CONTACT SUBJECT | The person who was the subject of the Care Contact. | R | 01 - Patient
02 - Patient Proxy |
CONSULTATION MECHANISM (MENTAL HEALTH) | The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS. | R | 01 - Face to face
02 - Telephone 04 - Talk type for a person unable to speak 05 - Email 09 - Text Message (Asynchronous) 10 - Instant messaging (Synchronous) 11 - Video consultation 12 - Message Board (Asynchronous) 13 - Chat Room (Synchronous) 98 - Other (not listed) |
ACTIVITY LOCATION TYPE CODE | The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent. | R | A01 Patient's home
A02 Carer's home A03 Patient's workplace A04 Other patient related location B01 Primary Care Health Centre B02 Polyclinic C01 General Medical Practitioner Practice C02 Dental Practice C03 Ophthalmic Medical Practitioner premises D01 Walk In Centre D02 Out of Hours Centre D03 Emergency Community Dental Service E01 Out-Patient Clinic E02 Ward E03 Day Hospital E04 Emergency Care Department or Minor Injuries Department E99 Other departments F01 Hospice G01 Care Home Without Nursing G02 Care Home With Nursing G03 Children’s Home G04 Integrated Care Home Without Nursing and Care Home With Nursing H01 Day Centre J01 Resource Centre K01 Sure Start Children’s Centre K02 Child Development Centre L01 School L02 Further Education College L03 University L04 Nursery Premises L05 Other Childcare Premises L06 Training Establishments L99 Other Educational Premises M01 Prison M02 Probation Service Premises M03 Police Station / Police Custody Suite M04 Young Offender Institution M06 Young Offender Institution (15-17) M07 Young Offender Institution (18-21) M05 Immigration Removal Centre N01 Street or other public open space N02 Other publicly accessible area or building N03 Voluntary or charitable agency premises N04 Dispensing Optician premises N05 Dispensing Pharmacy premises X01 Other locations not elsewhere classified 1 General Health Promotion Session 2 Telephone Support Sessiom 3 Thereputic Group Session |
PLACE OF SAFETY INDICATOR | An indication of whether a LOCATION is being used as a PLACE OF SAFETY. | R | Y - Yes – is being used as a Place of Safety
N - No – is not being used as a Place of Safety |
ORGANISATION SITE IDENTIFIER (OF TREATMENT) | The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated. | R | |
COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR | An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service. | R | Y - Yes - a Community Perinatal Mental Health Partner Assessment has been offered
N - No - a Community Perinatal Mental Health Partner Assessment has not been offered |
PLANNED CARE CONTACT INDICATOR | An indication as to whether a Care Contact is a result of a Planned Appointment. | R | Y - Yes - the care contact is a result of a planned Appointment
N - No - the care contact is not a result of a planned appointment |
CARE CONTACT PATIENT THERAPY MODE | The mode of therapy for the patient during a Care Contact. | R | 1 - Individual patient
2 - Couple 3 - Group Therapy |
ATTENDED OR DID NOT ATTEND CODE | This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given. | R | 5 - Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT
6 - Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen 7 - Patient arrived late and could not be seen 2 - APPOINTMENT cancelled by, or on behalf of, the PATIENT 3 - Did not attend - no advance warning given 4 - Appointment cancelled or postponed by the health care provider |
EARLIEST REASONABLE OFFER DATE | The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission. | R | |
EARLIEST CLINICALLY APPROPRIATE DATE | The earliest DATE that it was clinically appropriate for an ACTIVITY to take place. | R | |
CARE CONTACT CANCELLATION DATE | The date that a Care Contact was cancelled by the Provider or Patient. | R | |
CARE CONTACT CANCELLATION REASON | The reason that a Care Contact was cancelled. | R | 01 - Cancelled for Clinical Reasons
02 - Cancelled for Non-clinical Reasons |
REASONABLE ADJUSTMENT MADE INDICATOR | Was a reasonable adjustment made for this patient? | R | Y - Yes - a Reasonable Adjustment was made for the patient
N - No - a Reasonable Adjustment was not made for the patient X - Not applicable |
Care Activity
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE ACTIVITY IDENTIFIER | The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned. | M | |
CLINICAL CONTACT DURATION OF CARE ACTIVITY | The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY. | R | |
CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. | R | |
FINDING SCHEME IN USE (MENTAL HEALTH) | The code scheme basis of a finding. | R | 01 - ICD-10
04 - SNOMED CT® |
CODED FINDING (CODED CLINICAL ENTRY) | A unique identifier for a finding from a specific classification or clinical terminology. | R | |
CODED OBSERVATION (SNOMED CT) | A unique identifier for an observation from a specific clinical terminology. | R | |
OBSERVATION VALUE | The numeric value resulting from a clinical observation. | R | |
UCUM UNIT OF MEASUREMENT | The unit of measurement used to measure the result of a clinical observation. See http://unitsofmeasure.org/trac/. | R |
Other in Attendance
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
OTHER PERSON IN ATTENDANCE AT CARE CONTACT | The other PERSON in attendance, with the PATIENT, at the CARE CONTACT. | M | 01 - Independent Advocate (Family Member)
02 - Independent Advocate (Independent Person) 03 - Independent Mental Capacity Advocate (IMCA) 04 - Independent Mental Health Advocate (IMHA) 05 - Non-Instructed Advocate 10 - Parent or relative (Non-Advocate) 11 - Friend or neighbour (Non-Advocate) 12 - Care Worker (Non-Advocate) |
REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE | Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care | R | 01 - PATIENT has chosen not to have an Independent Mental Health Advocate
02 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken 03 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought 04 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken 05 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought 98 - Other (not listed) 99 - Not applicable (no requirement for an Independent Mental Capacity Advocate) |
REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE | Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care | R | 01 - Patient has chosen not to have an Independent Mental Health Advocate
02 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken 03 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought 04 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken 05 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought 98 - Other (not listed) 99 - Not applicable (no requirement for an Independent Mental Health Advocate) |
Indirect Activity
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
INDIRECT ACTIVITY DATE | The date that the indirect activity took place | M | |
INDIRECT ACTIVITY TIME | The time that the indirect activity took place | R | |
DURATION OF INDIRECT ACTIVITY | The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided. | R | |
CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT) | The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed. | R |
Group Session
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
GROUP SESSION IDENTIFIER | The GROUP SESSION IDENTIFIER is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned. | M | |
GROUP SESSION DATE | The date that a Group Session took place, or, if cancelled, was scheduled to take place. | M | |
CLINICAL CONTACT DURATION OF GROUP SESSION | The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided. | R | |
GROUP SESSION TYPE (MENTAL HEALTH) | The type of Group Session provided by a Mental Health Service. | R | 01 - General Health Promotion Session
02 - Telephone Support Session 03 - Therapeutic Group Session |
NUMBER OF GROUP SESSION PARTICIPANTS | The number of persons who participated in the Group Session excluding the care professionals. | R |
Mental Health Drop In Contact
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
MENTAL HEALTH DROP IN CONTACT IDENTIFIER | The Mental Health DROP IN CONTACT IDENTIFIER is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned. | M | |
CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT) | The date that a Drop In Contact took place. | M | |
MENTAL HEALTH DROP IN CONTACT SERVICE TYPE | The type of SERVICE where the Mental Health Drop In Contact took place. | R | A17 - Memory Services/Clinic/Drop In Service
A19 - 24/7 Crisis Response Line A21 - Crisis Café/Safe Haven/Sanctuary Service |
START TIME (MENTAL HEALTH DROP IN CONTACT) | The Start Time of the Mental Health Drop In Contact as reported by the Care Professional. | R | |
END TIME (MENTAL HEALTH DROP IN CONTACT) | The End Time of the Mental Health Drop In Contact as reported by the Care Professional. | R | |
MENTAL HEALTH DROP IN CONTACT OUTCOME | The outcome of the Mental Health Drop In Contact as reported by the Care Professional. | R | 01 - Caller Disconnected
02 - Advice on call only 03 - Signposted to other non-NHS services sources of support 04 - Non-urgent referral to other NHS service 05 - Urgent referral for face to face assessment 06 - Emergency Service(s) notified 98 - Other (not listed) |
Mental Health Act Legal Status Classification Assignment Period
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER | A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. | M | |
START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | The Start Date of the Mental Health Act Legal Status Classification Assignment Period. | M | |
START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | The Start Time of the Mental Health Act Legal Status Classification Assignment Period. | M | |
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON | The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period. | R | 01 - Change in Mental Health Act Legal Status Classification Code (including from informal)
04 - Transfer from other Health Care Provider |
EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) | The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. | R | |
EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION) | The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires. | R | |
END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | The date on which the Mental Health Act Legal Status Classification Assignment Period ended. | R | |
END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD) | The time on which the Mental Health Act Legal Status Classification Period ended. | R | |
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON | The reason for the end of the Mental Health Act Legal Status Classification Assignment Period. | R | 01 - Change in Mental Health Act Legal Status Classification Code (including to informal)
04 - Transfer to other Health Care Provider 05 - Death of patient |
MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE | 'A code to identify the classification of Mental Health Act Legal Status. | R | 01 - Informal
02 - Formally detained under Mental Health Act Section 2 03 - Formally detained under Mental Health Act Section 3 04 - Formally detained under Mental Health Act Section 4 05 - Formally detained under Mental Health Act Section 5 (2) 06 - Formally detained under Mental Health Act Section 5 (4) 07 - Formally detained under Mental Health Act Section 35 08 - Formally detained under Mental Health Act Section 36 09 - Formally detained under Mental Health Act Section 37 with section 41 restrictions 10 - Formally detained under Mental Health Act Section 37 12 - Formally detained under Mental Health Act Section 38 13 - Formally detained under Mental Health Act Section 44 14 - Formally detained under Mental Health Act Section 46 15 - Formally detained under Mental Health Act Section 47 with section 49 restrictions 16 - Formally detained under Mental Health Act Section 47 17 - Formally detained under Mental Health Act Section 48 with section 49 restrictions 18 - Formally detained under Mental Health Act Section 48 19 - Formally detained under Mental Health Act Section 135 20 - Formally detained under Mental Health Act Section 136 31 - Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991 32 - Formally detained under other acts 35 - Subject to guardianship under Mental Health Act Section 7 36 - Subject to guardianship under Mental Health Act Section 37 37 - Formally detained under Mental Health Act Section 45A (Limited direction in force) 38 - Formally detained under Mental Health Act Section 45A (Limitation direction ended) 98 - Not Applicable 99 - Not Known |
MENTAL HEALTH ACT 2007 MENTAL CATEGORY | The primary reason for the detention of PATIENTS. | R | A - Mental disorder (Learning Disability not present or not primary reason for using Act)
B - Mental disorder (Learning Disability primary reason for using Act) 8 - Not applicable (i.e. not detained) 9 - Not Known (Not Recorded) |
Mental Health Responsible Clinician Assignment Period
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) | The start date of an assignment of a Mental Health Responsible Clinician to a patient. | M | |
END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) | The end date of an assignment of a Mental Health Responsible Clinician to a patient. | R |
Conditional Discharge
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) | The start date of the Mental Health Conditional Discharge Period. | M | |
END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) | The end date of the Mental Health Conditional Discharge Period. | R | |
MENTAL HEALTH CONDITIONAL DISCHARGE END REASON | The reason a Mental Health Conditional Discharge Period ended. | R | 01 - Mental Health absolute discharge
02 - Recall of PATIENT 03 - Death of PATIENT |
MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY | The body or PERSON responsible for granting Mental Health Absolute Discharge. | R | 01 - Mental Health Tribunal
02 - Secretary of State |
Community Treatment Order Recall
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (COMMUNITY TREATMENT ORDER RECALL) | The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | M | |
EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL) | The date which the Community Treatment Order for a patient was due to expire. This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended | R | |
END DATE (COMMUNITY TREATMENT ORDER RECALL) | The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | R | |
COMMUNITY TREATMENT ORDER END REASON | The reason for the termination of a period of a Community Treatment Order. | R | 01 - Patient discharged
02 - Community Treatment Order revoked 03 - Patient died 04 - Patient transferred outside England 05 - Patient transferred to another Health Care Provider |
Community Treatment Order Recall
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START TIME (COMMUNITY TREATMENT ORDER RECALL) | The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | M | |
END TIME (COMMUNITY TREATMENT ORDER RECALL) | The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). | R |
Hospital Provider Spell
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
HOSPITAL PROVIDER SPELL IDENTIFIER | A unique identifier for each Hospital Provider Spell for a Health Care Provider. | M | |
DECIDED TO ADMIT DATE | The date a DECISION TO ADMIT was made. | R | |
DECIDED TO ADMIT TIME | The time a DECISION TO ADMIT was made. | R | |
START DATE (HOSPITAL PROVIDER SPELL) | The start date of a Hospital Provider Spell. | M | |
START TIME (HOSPITAL PROVIDER SPELL) | The start time of a Hospital Provider Spell. | R | |
ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | The source of admission to a Hospital Provider Spell. | R | 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
29 - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments) 37 - Court 40 - Penal establishment 42 - Police Station / Police Custody Suite 49 - NHS other Hospital Provider - high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) 51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department 52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates 53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities 55 - Care Home With Nursing 56 - Care Home Without Nursing 66 - Local Authority foster care 87 - Independent Sector Healthcare Provider run hospital 88 - Hospice 98 - Not applicable 99 - Not Known |
METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission. | R | 11 - Elective Admission: Waiting list
12 - Elective Admission: Booked 13 - Elective Admission: Planned 21 - Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE 22 - Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy 23 - Emergency Admission: Bed bureau 24 - Emergency Admission: Consultant Clinic, of this or another Health Care Provider 25 - Emergency Admission: Admission via Mental Health Crisis Resolution Team 2A - Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted 2B - Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency 2D - Emergency Admission: Other emergency admission 81 - Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency 98 - Not applicable 99 - Not Known |
POSTCODE OF MAIN VISITOR | The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell. | R | |
ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | The estimated discharge date from a Hospital Provider Spell. | R | |
PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | The planned discharge date from a Hospital Provider Spell. | R | |
PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) | The planned destination of a PATIENT on completion of a Hospital Provider Spell. | R | 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment) 30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) 37 - Court 40 - Penal establishment 42 - Police Station / Police Custody Suite 48 - High Security Psychiatric Hospital, Scotland 49 - NHS other Hospital Provider - high security psychiatric accommodation 50 - NHS other Hospital Provider - medium secure unit 51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled 52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates 53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities 55 - Care Home With Nursing 56 - Care Home Without Nursing 66 - Local Authority foster care 79 - PATIENT died or stillbirth 84 - Independent Sector Healthcare Provider run hospital - medium secure unit 87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit 88 - Hospice 89 - ORGANISATION responsible for forced repatriation 98 - Not applicable 99 - Not known |
DISCHARGE DATE (HOSPITAL PROVIDER SPELL) | The discharge date from a Hospital Provider Spell. | R | |
DISCHARGE TIME (HOSPITAL PROVIDER SPELL) | The discharge time from a Hospital Provider Spell. | R | |
METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL) | The method of discharge from a Hospital Provider Spell. | R | 1 - Patient discharged on clinical advice or with clinical consent
3 - Patient discharged by mental health review tribunal, Home Secretary or court 4 - Patient died 6 - Patient discharged him/herself 7 - Patient discharged by a relative or advocate 8 - Not applicable (Hospital Provider Spell not finished at episode end (i.e. not discharged) or current episode unfinished) 9 - Method of Discharge not known |
DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL) | The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died. | R | 19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.
29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment) 30 - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust or NHS Foundation Trust) 37 - Court 40 - Penal establishment 42 - Police Station / Police Custody Suite 48 - High Security Psychiatric Hospital, Scotland 49 - NHS other Hospital Provider - high security psychiatric accommodation 50 - NHS other Hospital Provider - medium secure unit 51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled 52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates 53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities 55 - Care Home With Nursing 56 - Care Home Without Nursing 66 - Local Authority foster care 79 - PATIENT died or stillbirth 84 - Independent Sector Healthcare Provider run hospital - medium secure unit 87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit 88 - Hospice 89 - ORGANISATION responsible for forced repatriation 98 - Not applicable 99 - Not known |
POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) | The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell. | R | |
TRANSFORMING CARE INDICATOR | Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care | R | Y - Yes - Patient is in scope of transforming care
N - No - Patient is not in scope of transforming care |
TRANSFORMING CARE CATEGORY | Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care | R | 1 - Patient with autism (and no learning disability)
2 - Patient with a learning disability (and no autism) 3 - Patient with autism and a learning disability |
Ward Stay
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
WARD STAY IDENTIFIER | A unique identifier allocated for each Ward Stay during the hospital provider spell. | M | |
START DATE (WARD STAY) | The start date of a ward stay. | M | |
START TIME (WARD STAY) | The start time of a ward stay. | R | |
END DATE (MENTAL HEALTH TRIAL LEAVE) | The End Date of a period of Mental Health Trial Leave for a PATIENT. | R | |
END DATE (WARD STAY) | The end date of a ward stay. | R | |
END TIME (WARD STAY) | The end time of a ward stay. | R | |
WARD SETTING TYPE (MENTAL HEALTH) | The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell. | R | 01 - Child and Adolescent Mental Health Ward
02 - Paediatric Ward 03 - Adult Mental Health Ward 04 - Non Mental Health Ward 05 - Learning Disabilities Ward 06 - Older People's Mental Health Ward |
INTENDED AGE GROUP (MENTAL HEALTH) | The age group of PATIENTS intended to use a WARD indicated in the operational plan. | R | 10 - Child only
11 - Adolescent only 12 - Child and Adolescent 13 - Adult only 14 - Older Adult only 15 - Adult and Older Adult 99 - Any age |
SEX OF PATIENTS CODE (MENTAL HEALTH) | The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed. | R | 1 - Male
2 - Female 8 - Not specified |
INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) | The intended level of resources and intensity of care for the ward in which the person is placed. | R | 51 - Mental Illness intensive care: specially designated ward for Patients needing containment and more intensive management (e.g. Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where Patients may require one to one nursing while on a standard ward
52 - Mental Illness short stay: Patients intended to stay less than a year 53 - Mental Illness long stay: Patients intended to stay a year or more 61 - Learning Disability Patients in a designated or interim secure unit 62 - Learning Disability Patients intending to stay less than a year 63 - Learning Disability Patients intending to stay a year or more |
WARD SECURITY LEVEL | The level of security for a ward. | R | 0 - General (non-secure)
1 - Low Secure 2 - Medium Secure 3 - High Secure |
LOCKED WARD INDICATOR | An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit. | R | Y - Yes - is a locked WARD
N - No - is not a locked WARD |
MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION | The classification of the admitted PATIENT during a Ward Stay. | R | 10 - Acute adult mental health care
11 - Acute older adult mental health care (organic and functional) 12 - Adult Psychiatric Intensive Care Unit (acute mental health care) 13 - Adult Eating Disorders 14 - Mother and baby 15 - Adult Learning Disabilities 17 - Adult High dependency rehabilitation 19 - Adult Low secure 20 - Adult Medium secure 21 - Adult High secure 22 - Adult Neuro-psychiatry / Acquired Brain Injury 23 - General child and young PERSON admitted PATIENT - Child (including High Dependency) 24 - General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency) 25 - Eating Disorders admitted patient - Young person (13 years and over) 26 - Eating Disorders admitted patient - Child (12 years and under) 27 - Child and Young Person Low Secure Mental Illness 28 - Child and Young Person Medium Secure Mental Illness 29 - Child Mental Health admitted patient services for the Deaf 30 - Child and Young Person Learning Disabilities / Autism admitted patient 31 - Child and Young Person Low Secure Learning Disabilities 32 - Child and Young Person Medium Secure Learning Disabilities 33 - Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person 34 - Child and Young Person Psychiatric Intensive Care Unit 35 - Adult admitted patient continuing care 36 - Adult community rehabilitation unit 37 - Adult highly specialist high dependency rehabilitation unit 38 - Adult longer term high dependency rehabilitation unit 39 - Adult mental health admitted patient services for the Deaf 40 - Adult personality disorder |
WARD CODE | A unique identification of a WARD within a Health Care Provider. | R |
Assigned Care Professional
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) | The start date of an assignment of a Care Professional responsible for the care of the patient. | M | |
END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) | The end date of an assignment of a Care Professional responsible for the care of the patient. | R | |
TREATMENT FUNCTION CODE (MENTAL HEALTH) | 'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest. | R | 319 Respite Care Service
348 Post-COVID-19 Syndrome Service 656 Clinical Psychology Service 700 Learning Disability Service 710 Adult Mental Health Service 711 Child and Adolescent Psychiatry Service 712 Forensic Psychiatry Service 713 Medical Psychotherapy Service 715 Old Age Psychiatry Service 720 Eating Disorders Service 721 Addiction Service 722 Liaison Psychiatry Service 723 Psychiatric Intensive Care Service 724 Perinatal Mental Health Service 725 Mental Health Recovery and Rehabilitation Service 726 Mental Health Dual Diagnosis Service 727 Dementia Assessment Service 730 Neuropsychiatry Service |
Mental Health Delayed Discharge
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) | The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place. | M | |
END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) | The date that a period of delayed discharge for a patient who had previously been ready for discharge ended. This may end because the patient was discharged or because the patient was no longer ready for discharge. | R | |
MENTAL HEALTH DELAYED DISCHARGE REASON | The reason that a patient was not able to be discharged despite being medically ready for discharge. | R | A2 - Awaiting care coordinator allocation
B1 - Awaiting public funding C1 - Awaiting further non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc) D1 - Awaiting Care Home Without Nursing placement or availability D2 - Awaiting Care Home With Nursing placement or availability E1 - Awaiting care package in own home F2 - Awaiting community equipment, telecare and/or adaptations G2 - Patient or Family choice (reason not stated by patient or family) G3 - Patient or Family choice - Non-acute (including community and mental health) NHS care (including intermediate care, rehabilitation services etc) G4 - Patient or Family choice - Care Home Without Nursing placement G5 - Patient or Family choice - Care Home With Nursing placement G6 - Patient or Family choice - Care package in own home G7 - Patient or Family choice - Community equipment, telecare and/or adaptations G8 - Patient or Family Choice - general needs housing/private landlord acceptance as patient NOT covered by Housing Act/Care Act G9 - Patient or Family choice - Supported accommodation G10 - Patient or Family choice - Emergency accommodation from the Local Authority under the Housing Act G11 - Patient or Family choice - Child or young person awaiting social care or family placement G12 - Patient or Family choice - Ministry of Justice agreement/permission of proposed placement H1 - Disputes I2 - Housing - Awaiting availability of general needs housing/private landlord accommodation acceptance as patient NOT covered by Housing Act and/or Care Act I3 - Housing - Single homeless patients or asylum seekers NOT covered by Care Act J2 - Housing - Awaiting supported accommodation K2 - Housing - Awaiting emergency accommodation from the Local Authority under the Housing Act L1 - Child or young person awaiting social care or family placement M1 - Awaiting Ministry of Justice agreement/permission of proposed placement N1 - Awaiting outcome of legal requirements (mental capacity/mental health legislation) P1 - Awaiting residential special school or college placement or availability Q1 - Lack of local education support R1 - Public safety concern unrelated to clinical treatment need (care team) R2 - Public safety concern unrelated to clinical treatment need (Ministry of Justice) S1 - No lawful community care package available T1 - Lack of health care service provision T2 - Lack of social care support 98 - No reason given |
MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE | An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable. | R | 04 - NHS, excluding housing
05 - Social Care, excluding housing 06 - Both (NHS and Social Care), excluding housing 07 - Housing (including supported/specialist housing) |
ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE) | The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period. | R |
Restrictive Intervention Incident
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER | A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell | M | |
START DATE (RESTRICTIVE INTERVENTION INCIDENT) | The Start Date of the Restrictive Intervention Incident as reported by the Care Professional. | M | |
START TIME (RESTRICTIVE INTERVENTION INCIDENT) | The Start Time of the Restrictive Intervention Incident as reported by the Care Professional. | R | |
END DATE (RESTRICTIVE INTERVENTION INCIDENT) | The End Date of the Restrictive Intervention Incident as reported by the Care Professional. | R | |
END TIME (RESTRICTIVE INTERVENTION INCIDENT) | The End Time of the Restrictive Intervention Incident as reported by the Care Professional. | R | |
RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT) | An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention. | R | Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention |
RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT) | The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention. | R | 1 - Clinical decision to delay
2 - Patient refused to take part 3 - Other (not listed) |
RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL) | An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention. | R | Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention
N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention |
RESTRICTIVE INTERVENTION REASON | The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell. | R | 10 - Prevent a patient being violent to others
11 - Prevent a patient causing serious intentional harm to themselves 12 - Prevent a patient causing serious physical injury to themselves by accident 13 - Lawfully administer medicines or other medical treatment 14 - Facilitate personal care 15 - Facilitate nasogastric (NG) feeding 16 - Prevent the patient exhibiting extreme and prolonged over-activity 17 - Prevent the PATIENT exhibiting otherwise dangerous behaviour 18 - Undertake a search of the patient’s clothing or property to ensure the safety of others 19 - Prevent the patient absconding from lawful custody 98 - Other (not listed) 99 - Not Known (Not Recorded) |
Restrictive Intervention Type
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
RESTRICTIVE INTERVENTION TYPE IDENTIFIER | A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell | M | |
START DATE (RESTRICTIVE INTERVENTION TYPE) | The Start Date of the Restrictive Intervention Type as reported by the Care Professional. | M | |
START TIME (RESTRICTIVE INTERVENTION TYPE) | The Start Time of the Restrictive Intervention Type as reported by the Care Professional. | R | |
RESTRICTIVE INTERVENTION TYPE | Type of RESTRICTIVE INTERVENTION used. | R | 01 - Physical restraint - Prone
07 - Physical restraint - Standing 08 - Physical restraint - Restrictive escort 09 - Physical restraint - Supine 10 - Physical restraint - Side 11 - Physical restraint - Seated 12 - Physical restraint - Kneeling 13 - Physical restraint - Other (not listed) 14 - Chemical restraint - Injection (Rapid Tranquillisation) 15 - Chemical restraint - Injection (Non Rapid Tranquillisation) 16 - Chemical restraint - Oral 17 - Chemical restraint - Other (not listed) 04 - Mechanical restraint 05 - Seclusion 06 - Segregation |
END DATE (RESTRICTIVE INTERVENTION TYPE) | The End Date of the Restrictive Intervention Type as reported by the Care Professional. | R | |
END TIME (RESTRICTIVE INTERVENTION TYPE) | The End Time of the Restrictive Intervention Type as reported by the Care Professional. | R | |
RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT) | An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention. | R | Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention |
RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL) | An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention. | R | Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention |
RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON) | An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention. | R | Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention
N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention |
Police Assistance Request
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
POLICE ASSISTANCE REQUEST DATE | The date the call was made to request police assistance | M | |
POLICE ASSISTANCE REQUEST TIME | The time the call was made to request police assistance | R | |
POLICE ASSISTANCE ARRIVAL DATE | The date the Police arrived following the request for assistance | R | |
POLICE ASSISTANCE ARRIVAL TIME | The time the Police arrived following the request for assistance | R | |
POLICE RESTRAINT OR FORCE USED INDICATOR | An indication of whether the police used restraint or force on a PATIENT. | R | Y - Yes - the police used restraint or force on a PATIENT
N - No - the police did not use restraint or force on a PATIENT |
Assault
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DATE OF ASSAULT ON PATIENT | The DATE that an instance of assault on the PATIENT by another PATIENT occurred. | M |
Self-Harm
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DATE OF SELF-HARM | The date that an incident of self-harm for the patient occurred. | M | |
OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE) | The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL. | M |
Home Leave
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (HOME LEAVE) | The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. | M | |
START TIME (HOME LEAVE) | The start time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. | R | |
END DATE (HOME LEAVE) | The end date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. | R | |
END TIME (HOME LEAVE) | The end time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983. | R |
Leave Of Absence
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH LEAVE OF ABSENCE) | The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | M | |
START TIME (MENTAL HEALTH LEAVE OF ABSENCE) | The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | R | |
END DATE (MENTAL HEALTH LEAVE OF ABSENCE) | The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | R | |
END TIME (MENTAL HEALTH LEAVE OF ABSENCE) | The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. | R | |
MENTAL HEALTH LEAVE OF ABSENCE END REASON | The reason a Mental Health Leave of Absence ended. | R | 01 - Patient returned on or before day specified
02 - Leave revoked and patient recalled by Mental Health Responsible Clinician 03 - Period of leave to be extended 04 - Patient failed to return on or before day specified and is absent without leave 05 - Patient's liability for detention terminated by Mental Health Responsible Clinician 06 - Patient's liability for detention terminated by Mental Health Act Review Tribunal 07 - Patient's liability for detention terminated by Hospital Managers 08 - Patient died 96 - Other (not listed) 99 - MENTAL HEALTH LEAVE OF ABSENCE END REASON Not Known (Not Recorded) |
ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR | An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted. | R | Y - Yes - a period of Mental Health Leave of Absence is escorted
N - No - a period of Mental Health Leave of Absence is not escorted |
Mental Health Trial Leave
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (MENTAL HEALTH TRIAL LEAVE) | The Start Date of a period of Mental Health Trial Leave for a PATIENT. | M | |
START TIME (MENTAL HEALTH TRIAL LEAVE) | The Start Time of a period of Mental Health Trial Leave for a PATIENT. | R | |
END TIME (MENTAL HEALTH TRIAL LEAVE) | The End Time of a period of Mental Health Trial Leave for a PATIENT. | R |
Hospital Provider Spell Commissioner Assignment Period
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (COMMISSIONER ASSIGNMENT PERIOD) | The Start Date of the Commissioner Assignment Period. | M | |
END DATE (COMMISSIONER ASSIGNMENT PERIOD) | The End Date of the Commissioner Assignment Period. | R |
Specialised Mental Health Exceptional Package of Care
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE | The amount charged for the SMH EPC in the reporting period | M | |
START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) | The start date of an SMH EPC. | M | |
END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE) | The End Date of an SMH EPC. | R |
Medical History (Previous Diagnosis)
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DIAGNOSIS SCHEME IN USE (MENTAL HEALTH) | The code scheme basis of the Diagnosis. | M | 02 - ICD-10
06 - SNOMED CT® |
PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) | A unique identifier for a clinical diagnosis from a specific classification or clinical terminology. | M | |
CODED DIAGNOSIS TIMESTAMP | The date, time and time zone for the PATIENT DIAGNOSIS. | R |
Provisional Diagnosis
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) | This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare. | M |
Primary Diagnosis
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) | This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem. | M |
Secondary Diagnosis
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) | This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded. | M | |
CODED DIAGNOSIS TIMESTAMP | The date, time and time zone for the PATIENT DIAGNOSIS. | R |
Coded Scored Assessment (Referral)
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CODED ASSESSMENT TOOL TYPE (SNOMED CT) | The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT. | M | |
PERSON SCORE | The observable value (score) resulting from an assessment. | M | |
ASSESSMENT TOOL COMPLETION TIMESTAMP | The date, time and time zone on which the assessment took place | M |
Care Programme Approach (CPA) Care Episode
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER | A unique identifier allocated to each Care Programme Approach Care Episode. | M | |
START DATE (CARE PROGRAMME APPROACH CARE) | The start date for Care Programme Approach Care for the patient. | M | |
END DATE (CARE PROGRAMME APPROACH CARE) | The end date for Care Programme Approach Care for the patient. | R |
Care Programme Approach (CPA) Review
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PROGRAMME APPROACH REVIEW DATE | The date of the Care Programme Approach review. | M |
Clustering Tool Assessment
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CLUSTERING TOOL ASSESSMENT IDENTIFIER | A unique identifier for each clustering tool assessment that takes place for each patient. | M | |
CLUSTERING TOOL ASSESSMENT CATEGORY | The category of the clustering tool assessment completed. | M | 01 - Adult Mental Health Clustering Tool
03 - Learning Disabilities Clustering Tool 04 - Forensic Mental Health Clustering Tool 05 - Forensic Learning Disabilities Clustering Tool 06 - Child and Adolescent Mental Health Needs Based Grouping Tool |
ASSESSMENT TOOL COMPLETION DATE | The date on which a clustering tool assessment was completed for a patient. | M | |
ASSESSMENT TOOL COMPLETION TIME | The time on which a clustering tool assessment was completed for a patient. | R | |
CLUSTERING TOOL ASSESSMENT REASON | The reason that the clustering tool assessment for the patient was undertaken. | R | 10 - Initial assessment
11 - Scheduled re-assessment 12 - Re-assessment following significant unanticipated change in need 97 - Other Reason (not listed) 99 - CLUSTERING TOOL ASSESSMENT REASON Not Known (Not Recorded) |
MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE | The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation. | R | A - Non-Psychotic
B - Psychotic C - Organic Z - Unable to assign patient to Mental Health Care Cluster Super Class |
ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) | ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm. | R | 00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity) 02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need) 03 - Care Cluster 3 - Non-Psychotic (Moderate Severity) 04 - Care Cluster 4 - Non-Psychotic (Severe) 05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe) 06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas 07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability) 08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders 09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used. 10 - Care Cluster 10 - First Episode Psychosis 11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms) 12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability) 13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability) 14 - Care Cluster 14 - Psychotic Crisis 15 - Care Cluster 15 - Severe Psychotic Depression 16 - Care Cluster 16 - Dual Diagnosis 17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage) 18 - Care Cluster 18 - Cognitive Impairment (Low Need) 19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need) 20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need) 21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement) |
LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) | LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | P | |
FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) | FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | P |
Care Cluster
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (CARE CLUSTER ASSIGNMENT PERIOD) | The date on which the assignment of a patient to a Care Cluster started. | M | |
START TIME (CARE CLUSTER ASSIGNMENT PERIOD) | The time on which the assignment of a patient to a Care Cluster started. | R | |
ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) | ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm. | R | 00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)
01 - Care Cluster 1 - Common Mental Health Problems (Low Severity) 02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need) 03 - Care Cluster 3 - Non-Psychotic (Moderate Severity) 04 - Care Cluster 4 - Non-Psychotic (Severe) 05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe) 06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas 07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability) 08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders 09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used. 10 - Care Cluster 10 - First Episode Psychosis 11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms) 12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability) 13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability) 14 - Care Cluster 14 - Psychotic Crisis 15 - Care Cluster 15 - Severe Psychotic Depression 16 - Care Cluster 16 - Dual Diagnosis 17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage) 18 - Care Cluster 18 - Cognitive Impairment (Low Need) 19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need) 20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need) 21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement) |
CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE | The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL. | R | 10 - Getting Advice: Neurodevelopmental Assessment (NEU)
11 - Getting Advice: Signposting and Self-management Advice (ADV) 12 - Getting Help: Attention Deficit Hyperactivity Disorder (ADHD) 13 - Getting Help: Autism (AUT) 14 - Getting Help: Behavioural and/or Conduct Disorders (BEH) 15 - Getting Help: Bipolar Disorder (BIP) 16 - Getting Help: Depression (DEP) 17 - Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP) 18 - Getting Help: Obsessive compulsive disorder (OCD) 19 - Getting Help: Post-traumatic stress disorder (PTS) 20 - Getting Help: Self-harm (SHA) 21 - Getting Help: Social Anxiety Disorder (SOC) 22 - Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM) 23 - Getting Help: Co-occurring Emotional Difficulties (EMO) 24 - Getting Help: Difficulties Not Covered by Other Groupings (DNC) 25 - Getting More Help: Eating Disorders (EAT) 26 - Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP) 27 - Getting More Help: Psychosis (PSY) 28 - Getting More Help: Difficulties of Severe Impact (DSI) |
LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) | LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | P | |
FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) | FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. | R | 00 - Care Cluster 0: Variance
01 - Care Cluster 1: Common Mental Health Problems (Low Severity) 02 - Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need) 03 - Care Cluster 3: Non-Psychotic (Moderate Severity) 04 - Care Cluster 4: Non-Psychotic (Severe) 05 - Care Cluster 5: Non-Psychotic Disorders (Very Severe) 06 - Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas 07 - Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability) 08 - Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders 08b - Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders 10 - Care Cluster 10: First Episode Psychosis 11 - Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms) 12 - Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability) 13 - Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability) 14 - Care Cluster 14: Psychotic Crisis 15 - Care Cluster 15: Severe Psychotic Depression 16 - Care Cluster 16: Dual Diagnosis 17 - Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage) 18 - Care Cluster 18: Cognitive Impairment (Low Need) 19 - Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need) 20 - Care Cluster 20: Cognitive Impairment or Dementia (High Need) 21 - Care Cluster 21: Cognitive Impairment or Dementia (High Physical or Engagement) |
FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) | FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL. | P | |
END DATE (CARE CLUSTER ASSIGNMENT PERIOD) | The date on which the assignment of a patient to a Care Cluster ended. | R | |
END TIME (CARE CLUSTER ASSIGNMENT PERIOD) | The time on which the assignment of a patient to a Care Cluster ended. | R |
Five Forensic Pathways
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
FIVE FORENSIC PATHWAYS ASSESSMENT DATE | The date on which a Five Forensic Pathways assessment was completed for a patient. | M | |
FIVE FORENSIC PATHWAYS ASSESSMENT REASON | The reason for which a Five Forensic Pathways assessment was undertaken. | R | 10 - Initial Assessment
11 - Scheduled Re-Assessment 12 - Re-Assessment following significant unanticipated change in need 97 - Other Reason (not listed) 99 - Not Known (Not Recorded) |
FIVE FORENSIC PATHWAYS CODE | The Five Forensic Pathway assigned to a patient. | M | 0 - Unable to assign patient to one of the five forensic pathways
1 - Treatment responsive group 2 - Treatment resistant group – challenging behaviour 3 - Treatment resistant group – continuing care 4 - Personality disorder group – prison transfer 5 - Personality disorder group – co-morbidity |
Care Professionals
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PROFESSIONAL REGISTRATION BODY CODE | A code which identifies the PROFESSIONAL REGISTRATION BODY. | R | 01 - General Chiropractic Council
02 - General Dental Council 03 - General Medical Council 04 - General Optical Council 05 - Social Care Wales 08 - Health and Care Professions Council 09 - Nursing and Midwifery Council 16 - General Pharmaceutical Council 17 - General Osteopathic Council 18 - Social Work England |
PROFESSIONAL REGISTRATION ENTRY IDENTIFIER | The registration identifier allocated by an ORGANISATION. | R | |
CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) | The staff group of a CARE PROFESSIONAL working in a Mental Health Service. | R | 01 - Medical
02 - Nursing 03 - Psychology 04 - Primary Mental Health 05 - Child and Adolescent Psychotherapy 06 - Counselling 07 - Family and Systemic Psychotherapy 08 - Occupational Therapy 09 - Social Work 10 - Creative Therapy 11 - Other Therapy (Qualified) 12 - Education 13 - Speech and Language Therapy 97 - Other (Qualified) 98 - Other (Unqualified) |
MAIN SPECIALTY CODE (MENTAL HEALTH) | The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period. | R | 600 - General Medical Practice
700 - Learning Disability 710 - Adult Mental illness 711 - Child and Adolescent Psychiatry 712 - Forensic Psychiatry 713 - Medical Psychotherapy 715 - Old age psychiatry 950 - Nursing 960 - Allied Health Professional |
OCCUPATION CODE | An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual. | R | |
CARE PROFESSIONAL (JOB ROLE CODE) | A National Code for a POSITION applicable to an EMPLOYEE. | R |
IAPT
Data Linkage
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PERSONNEL LOCAL IDENTIFIER | A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system. | M |
Header
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DATA SET VERSION NUMBER | The version of the data set that this submission file is for. | M | |
ORGANISATION IDENTIFIER (CODE OF PROVIDER) | This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database | M | |
ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) | This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation. | M | |
PRIMARY DATA COLLECTION SYSTEM IN USE | The name of the Primary Data Collection System in use by the Health Care Provider. | M | |
REPORTING PERIOD START DATE | The reporting period start date to which this file refers | M | |
REPORTING PERIOD END DATE | The reporting period end date to which this file refers | M | |
DATE AND TIME DATE SET CREATED | Date/time this upload file was created | M |
MPI
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | The type of Educational Establishment that the student is attending. | R | 1 - School
2 - College 3 - University 4 - Other Educational Establishment not listed 8 - Not applicable (Patient is not a student) Z - Not stated (Patient asked but declined to provide a response) X - Not Known (Not Recorded) |
Employment Status
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SELF EMPLOYED INDICATOR | 'An indication of whether an employed person is self-employed. | R | Y - Yes - Employed as a self-employed worker
N - No - Not self employed 8 - Not Applicable (Person is unemployed) Z - Not stated (Person asked but declined to provide a response) |
SICKNESS ABSENCE INDICATOR | 'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness. | R | Y - Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness
N - No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness 8 - Not Applicable (The person is unemployed) Z - Not stated (Person asked but declined to provide a response) X - Not Known (Not Recorded) |
STATUTORY SICK PAY RECEIPT INDICATOR | 'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON. | R | Y - Yes - the person is currently in receipt of Statutory Sick Pay
N - No - the person is currently not in receipt of Statutory Sick Pay U - Unknown (Person asked and does not know or is not sure) Z - Not stated (Person asked but declined to provide a response) |
BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | 'An indication of whether a patient is currently receiving benefits, as stated by the patient. | R | Y - Yes - the PATIENT is currently in receipt of a benefit
N - No - the PATIENT is not currently in receipt of a benefit U - Unknown (Person asked and does not know or is not sure) Z - Not stated (Person asked but declined to provide a response) |
EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR | 'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient. | R | Y - Yes - receiving Employment and Support Allowance
N - No - not receiving Employment and Support Allowance U - Unknown (Patient asked and does not know or is not sure) Z - Not stated (Patient asked but declined to provide a response) |
UNIVERSAL CREDIT RECEIPT INDICATOR | 'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient. | R | Y - Yes - receiving Universal Credit
N - No - not receiving Universal Credit U - Unknown (Patient asked and does not know or is not sure) Z - Not stated (Patient asked but declined to provide a response) |
PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR | 'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient. | R | Y - Yes - receiving Personal Independence Payment
N - No - Not receiving Personal Independence Payment U - Unknown (Patient asked and does not know or is not sure) Z - Not stated (Patient asked but declined to provide a response) |
EMPLOYMENT SUPPORT SUITABILITY INDICATOR | 'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support. | R | Y - Yes - the patient is a suitable candidate for referral to Employment Support
N - No - the patient is not a suitable candidate for referral to Employment Support N/A - Not Applicable |
EMPLOYMENT SUPPORT REFERRAL DATE | The date the PATIENT was referred for Employment Support. | R |
Social & Personal Circumstances
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE | R |
Referral
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES | The source of referral to a Mental Health Service. | R | A1 - Primary Health Care: General Medical Practitioner Practice
A2 - Primary Health Care: Health Visitor A3 - Other Primary Health Care A4 - Primary Health Care: Maternity Service B1 - Self Referral: Self B2 - Self Referral: Carer/Relative C1 - Local Authority and Other Public Services: Social Services C2 - Local Authority and Other Public Services: Education Service / Educational Establishment C3 - Local Authority and Other Public Services: Housing Service D1 - Employer D2 - Employer: Occupational Health E1 - Justice System: Police E2 - Justice System: Courts E3 - Justice System: Probation Service E4 - Justice System: Prison E5 - Justice System: Court Liaison and Diversion Service E6 - Justice System: Youth Offending Team F1 - Child Health: School Nurse F2 - Child Health: Hospital-based Paediatrics F3 - Child Health: Community-based Paediatrics G1 - Independent sector - Medium Secure Inpatients G2 - Independent Sector - Low Secure Inpatients G3 - Other Independent Sector Mental Health Services G4 - Voluntary Sector H1 - Acute Secondary Care: Emergency Care Department H2 - Other secondary care specialty I1 - Temporary transfer from another Mental Health NHS Trust I2 - Permanent transfer from another Mental Health NHS Trust M1 - Other: Asylum Services M2 - Other: Telephone or Electronic Access Service M3 - Other: Out of Area Agency M4 - Other: Drug Action Team / Drug Misuse Agency M5 - Other: Jobcentre Plus M6 - Other SERVICE or agency M7 - Other: Single Point of Access Service M8 - Debt agency N1 - Stepped up from low intensity Improving Access to Psychological Therapies Service N2 - Stepped down from high intensity Improving Access to Psychological Therapies Service N4 - Other Improving Access to Psychological Therapies Service P1 - Internal Referral Q1 - Mental Health Drop In Service |
YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT. | R | |
PREVIOUS DIAGNOSED CONDITION INDICATOR | An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT. | R | Y - Yes - this is a recurrence of a previously diagnosed condition
N - No - this is not a recurrence of a previously diagnosed condition U - Unknown (Patient asked and does not know or is unsure) Z - Not stated (Patient asked but declined to provide a response) |
DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON | The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service. | R | Referred but not seen
50 - Not assessed
10 - Not suitable for IAPT service - no action taken or directed back to referrer 11 - Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient 12 - Discharged by mutual agreement following advice and support 13 - Referred to another therapy service by mutual agreement 14 - Suitable for IAPT service, but patient declined treatment that was offered 16 - Incomplete Assessment (Patient dropped out) 17 - Deceased (Seen but not taken on for a course of treatment) 95 - Not Known (Seen but not taken on for a course of treatment)
46 - Mutually agreed completion of treatment 47 - Termination of treatment earlier than Care Professional planned 48 - Termination of treatment earlier than patient requested 49 - Deceased (Seen and taken on for a course of treatment) 96 - Not Known (Seen and taken on for a course of treatment) |
SERVICE DISCHARGE DATE | The date a PATIENT was discharged from a SERVICE. | R |
Onward Referral
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | The reason why the patient was referred from one service to another service, which may be in the same or a different organisation. | R | 1 - Transfer of Clinical Responsibility
2 - For Opinion Only 3 - For Diagnostic Test Only 4 - New Referral (Non Transfer) 5 - Stepped up from low intensity Improving Access to Psychological Therapies Service 6 - Stepped down from high intensity Improving Access to Psychological Therapies Service 96 - Other (not listed) 98 - Onward Referral Reason Not Applicable 99 - Not Known (Not Recorded) |
Waiting Time Pauses
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER | The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION. | M | |
ACTIVITY SUSPENSION START DATE | The date on which the break from the ACTIVITY starts. | M | |
ACTIVITY SUSPENSION END DATE | The date on which the break from the ACTIVITY ends. | R | |
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON | The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set. Patient Initiated pause in the waiting period. | R | 1 - Patient unavailable due to holiday
2 - Patient unavailable due to other health needs 3 - Patient stated not available - other reason (not listed) |
Care Contact
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR | An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice. | R | Y - Yes - Appointment slot could be reallocated
N - No - Appointment slot could not be reallocated |
INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR | An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service. | M | Y - Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological
Therapies Long Term Condition Service N - No - the Improving Access to Psychological Therapies Contact was not provided by an Integrated Improving Access to Psychological Therapies Long Term Condition Service |
APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | The type of Improving Access to Psychological Therapies APPOINTMENT. | M | 1 - Assessment
2 - Treatment 3 - Assessment and treatment 4 - Review only 5 - Review and treatment 6 - Follow-up appointment after treatment end 10 - Employment Support 98 - Other (not listed) 99 - Not Known (Not Recorded) |
INTERNET ENABLED THERAPY PROGRAMME | The name of the Internet Enabled Therapy Programme delivered to a PATIENT. | R | |
NUMBER OF GROUP THERAPY PARTICIPANTS | The number of persons who participated in the Group Therapy, excluding the Care Professionals. | R | |
NUMBER OF GROUP THERAPY FACILITATORS | The number of Care Professionals who facilitated the Group Therapy. | R | |
PSYCHOTROPIC MEDICATION USAGE INDICATION CODE | An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT. | R | 1 - Prescribed but not taking
2 - Prescribed and taking 3 - Not Prescribed UU - Unknown (Patient asked and does not know or is not sure) ZZ - Not stated (Patient asked but declined to provide a response) |
LANGUAGE CODE (TREATMENT) | The language used for the delivery of treatment to the Patient. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions. | R | All Spoken Languages
- ISO 639-1 codes at http://www.loc.gov/standards/iso639-2/php/code_list.php
q1 - Braille (for people who are unable to see) q2 - American Sign Language q3 - Australian Sign Language q4 - British Sign Language q5 - Makaton (devised for children and adults with a variety of communication and Learning Disabilities) |
INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE | An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter. | R | 1 - Yes - Professional interpreter
2 - Yes - Family member or friend 3 - Yes - Another Person 4 - No - Interpreter not required 5 - No - Interpreter was required but did not attend X - Not Known (Not Recorded) |
Internet Therapy Log
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) | The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. | M | |
END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) | The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to. | M | |
INTERNET ENABLED THERAPY PROGRAMME | The name of the Internet Enabled Therapy Programme delivered to a PATIENT. | M | |
DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME | The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period. | M | |
INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR | An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy. | R | Y - Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy
N - No - an Internet Enabled Therapy Integrated Software Engine was not used as part of Internet Enabled Therapy |
Medical History Previous Diagnosis
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
DIAGNOSIS DATE | DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS. | R |
Long Term Condition
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY) | The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition. | M |
Presenting Complaints
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
PRESENTING COMPLAINT (CODED CLINICAL ENTRY) | The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL | M | |
PRESENTING COMPLAINT CODING SIGNIFICANCE | The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL. | R | 1 - Primary Presenting Complaint
2 - Secondary Presenting Complaint |
PRESENTING COMPLAINT RECORDED DATE | The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded. | R |
Care Cluster
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
END TIME (CARE CLUSTER ASSIGNMENT PERIOD) | The time on which the assignment of a patient to a Care Cluster ended. | R |
Care Personnel Qualification
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
CARE PERSONNEL LOCAL IDENTIFIER | A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system. | M | |
QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) | The qualification or individual accreditation attained or planned to be attained, by the Care Personnel. | M | 10 - Curriculum for Psychological Wellbeing Practitioners (PWP)
11 - Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT) 12 - Curriculum for Counselling for Depression (CfD) 13 - Curriculum for Couple Therapy for Depression (CTfD) / Curriculum for Behavioural Couples Therapy (BCT) for Depression 14 - Curriculum for Dynamic Interpersonal Therapy (DIT) for Depression 15 - Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT) 16 - Curriculum for Mindfulness-based Cognitive Therapy (MBCT) 17 - Curriculum for Eye Movement Desensitisation Reprocessing (EMDR) 30 - Curriculum for Employment Advisers 31 - Curriculum for Senior Employment Advisers |
EMPLOYEE QUALIFICATION AWARDED DATE | The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course. | R | |
EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE | The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying. | R |
Freeform Placeholder
Name | Description | Conformance | Codes & Primary Value Set |
---|---|---|---|
FREEFORM NOTES | Any related notes deemed useful for inclusion within the DDS | R |