MHSDS User Guidance

Mental Health Service Data Set

Contents

Introduction ...... 12 Including patients in the MHSDS extract ...... 12 Excluding patients from the MHSDS extract ...... 12 MHS000 MHSDS Header ...... 12 M000010 Data Set Version Number ...... 12 M000080 Organisation Identifier (code of provider)...... 12 M000090 Organisation Identifier (code of submitting organisation) ...... 12 M000040 Primary Data Collection System In Use ...... 12 M000050 Reporting Period Start Date ...... 13 M000060 Reporting Period End Date ...... 13 M000070 Date and Time Data Set Created ...... 13 MHS001 Master Patient Index ...... 13 M001901 Local Patient Identifier (Extended) ...... 13 M001170 Organisation Identifier (local patient identifier) ...... 13 M001180 Organisation Identifier (residence responsibility) ...... 13 M001190 Organisation Identifier (educational establishment) ...... 13 M001040 NHS Number ...... 13 M001050 NHS Number Status Indicator Code ...... 13 M001060 Person Birth Date ...... 13 M001070 Postcode of Usual Address ...... 13 M001090 Person Stated Gender Code ...... 14 M001150 Person Marital Status ...... 14

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M001100 Ethnic Category ...... 14 M001120 Code (Preferred) ...... 16 M001130 Person Death Date...... 25 MHS002 GP Practice Registration ...... 25 M002901 Local Patient Identifier (Extended) ...... 25 M002010 General Medical Practice Code (Patient Registration) ...... 25 M002020 Start Date (GMP Patient Registration) ...... 25 M002030 End Date (GMP Patient Registration) ...... 26 M002050 Organisation Identifier (GP Practice Responsibility) ...... 26 MHS003 Accommodation Status ...... 26 M003901 Local Patient Identifier (Extended) ...... 26 M003010 Accommodation Status Code ...... 26 M003020 Settled Accommodation Indicator ...... 29 M003030 Accommodation Status Recorded Date ...... 29 M003040 Secure Children’ Home Placement Type ...... 29 MHS004 Employment Status ...... 29 M004901 Local Patient Identifier (Extended) ...... 29 M004010 Employment Status ...... 30 M004020 Employment Status Recorded Date ...... 30 M004030 Weekly Hours Worked ...... 30 MHS005 Patient Indicators ...... 31 M005901 Local Patient Identifier (Extended) ...... 31 M005010 Constant Supervision and Care Required Due to Disability Indicator ...... 31 M005020 Young Carer Indicator ...... 31 M005030 Looked After Child Indicator ...... 31 M005040 Child Protection Plan Indication Code ...... 32 M005100 Ex-British Armed Forces Indicator ...... 32 M005110 Offence History Indication Code ...... 32 M005120 Parental responsibilities indicator ...... 33 M005050 Prodrome Psychosis Date ...... 33 M005060 Emergent Psychosis Date ...... 33 M005070 Manifest Psychosis Date ...... 33 M005080 First Prescription Date (Anti-psychotic medication) ...... 33 M005090 Psychosis First Treatment Start Date ...... 33 MHS006 Mental Health Care Coordinator ...... 34 M006901 Local Patient Identifier (Extended) ...... 34 M006010 Start Date (Mental Health Care Coordinator Assignment Period) ...... 34 M006908 Care Professional Local Identifier ...... 34 M006030 End Date (Mental Health Care Coordinator Assignment Period) ...... 34 M006040 Care Professional Service or Team Type Association (Mental Health) ...... 34

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 2 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS007 Disability Type ...... 36 M007901 Local Patient Identifier (Extended) ...... 36 M007010 Disability code ...... 36 M007020 Disability Impact Perception ...... 39 MHS008 Mental Health Care Plan Type ...... 41 M008070 Care Plan Identifier ...... 41 M008901 Local Patient Identifier (Extended) ...... 41 M008030 Care Plan Type (Mental Health) ...... 41 M008010 Care Plan Creation Date ...... 41 M008080 Care Plan Creation Time ...... 42 M008020 Care Plan Last Updated Date ...... 42 M008090 Care Plan Last Updated Time ...... 42 MHS010 Assistive Technology To Support Disability Type ...... 42 MHS011 Social and Personal Circumstances ...... 42 M011901 Local Patient Identifier (Extended) ...... 42 M011020 Social and Personal Circumstance (SNOMED CT) ...... 42 M011010 Social and Personal Circumstance Recorded Date ...... 43 MHS012 Overseas Visitor Charging Category ...... 43 M012901 Local Patient Identifier ...... 43 M012010 Overseas Visitor Charging Category ...... 43 M012020 Overseas Visitor Charging Category Applicable Date ...... 44 MHS101 Service or Team Referral...... 44 M101902 Service Request Identifier ...... 44 M101901 Local Patient Identifier (Extended) ...... 44 M101922 Organisation Identifier (Code of Commissioner) ...... 44 M101010 Referral Request Received Date ...... 44 M101020 Referral Request Received Time ...... 44 M101907 NHS Service Line Number ...... 44 M101030 Source of Referral for Mental Health ...... 44 M101180 Organisation Identifier (Referring) ...... 48 M101050 Referring Care Professional Staff Group (Mental Health and Community Care) ...... 49 M101070 Clinical Response Priority Type ...... 50 M101080 Primary Reason For Referral (Mental Health) ...... 50 M101140 Reason For Out Of Area Referral (Adult Acute Mental Health) ...... 51 M101120 Discharge Plan Creation Date ...... 52 M101913 Discharge Plan Creation Time ...... 52 M101130 Discharge Plan Last Updated Date ...... 52 M101200 Discharge Plan Last Updated Time ...... 52 M101090 Service Discharge Date ...... 52 M101110 Service Discharge Time ...... 52

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 3 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M101100 Discharge Letter Issues Date (Mental Health and Community Care) ...... 52 MHS102 Service or Team Type Referred To ...... 52 M102905 Care Professional Team Local Identifier ...... 52 M102902 Service Request Identifier ...... 52 M102010 Service or Team Type referred to (Mental Health) ...... 53 M102020 Child and Adolescent Mental Health Tier or Service ...... 54 M102040 Referral Closure Date ...... 54 M102080 Referral Closure Time ...... 55 M102050 Referral Rejection Date ...... 55 M102090 Referral Rejection Time ...... 55 M102060 Referral Closure Reason ...... 55 M102070 Referral Rejection Reason ...... 55 MHS103 Other Reason for Referral ...... 56 M103902 Service Request Identifier ...... 56 M103010 Other Reason for Referral (Mental Health) ...... 56 MHS104 Referral to Treatment ...... 57 M104902 Service Request Identifier ...... 57 M104020 Patient Pathway Identifier ...... 57 M104080 Organisation Identifier (Patient Pathway Identifier Issuer)...... 57 M104040 Waiting Time Measurement Type ...... 57 M104050 Referral to Treatment Period Start Date ...... 57 M104060 Referral to Treatment Period End Date ...... 57 M104070 Referral to Treatment Period Status ...... 57 MHS105 Onward Referral ...... 59 M105902 Service Request Identifier ...... 59 M105010 Onward Referral Date ...... 59 M105060 Onward Referral Time ...... 59 M105020 Onward Referral Reason ...... 60 M105050 Reason For Out Of Area Referral (Adult Acute Mental Health) ...... 60 M105090 Organisation Identifier (Receiving) ...... 60 MHS107 Medication Prescription ...... 60 MHS201 Care Contact ...... 61 M201903 Care Contact Identifier ...... 61 M201902 Service Request Identifier ...... 61 M201905 Care Professional Team Local Identifier ...... 61 M201010 Care Contact Date ...... 61 M201020 Care Contact Time ...... 61 M201922 Organisation Identifier (Code of Commissioner) ...... 61 M201030 Administrative Category Code ...... 61 M201040 Clinical Contact Duration of Care Contact ...... 62

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 4 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M201050 Consultation Type ...... 62 M201060 Care Contact Subject ...... 62 M201070 Consultation Medium Used ...... 62 M201909 Activity Location Type Code ...... 63 M201160 Place of Safety Indicator ...... 65 M201921 Organisation Site Identifier (Of Treatment) ...... 65 M201080 Group Therapy Indicator ...... 65 M201090 Attended or Did Not Attend Code ...... 66 M201100 Earliest Reasonable Offer Date ...... 66 M201110 Earliest Clinically Appropriate Date ...... 67 M201120 Care Contact Cancellation Date ...... 67 M201130 Care Contact Cancellation Reason ...... 67 M201140 Replacement Appointment Date Offered ...... 67 M201150 Replacement Appointment Booked Date ...... 67 MHS202 Care Activity ...... 67 M202904 Care Activity Identifier ...... 67 M202903 Care Contact Identifier ...... 67 M202908 Care Professional Local Identifier ...... 68 M202020 Clinical Contact Duration of Care Activity ...... 68 M202110 Coded Procedure and Procedure Status (SNOMED CT) ...... 68 M202050 Finding Scheme in Use ...... 68 M202060 Coded Finding (Coded Clinical Entry)...... 68 M202070 Observation Scheme in Use ...... 68 M202080 Coded Observation (Clinical Terminology) ...... 68 M202090 Observation Value ...... 69 M202100 UCUM Unit of Measurement ...... 69 MHS203 Other in Attendance ...... 69 M203903 Care Contact Identifier ...... 69 M203010 Other Person in Attendance at Care Contact ...... 69 MHS204 Indirect Activity ...... 69 M204902 Service Request Identifier ...... 69 M204905 Care Professional Team Local Identifier ...... 70 M204010 Indirect Activity Date ...... 70 M204020 Indirect Activity Time ...... 70 M204030 Duration of Indirect Activity ...... 70 M204922 Organisation Identifier (Code of Commissioner) ...... 70 M204908 Care Professional Local Identifier ...... 70 M204070 Coded Procedure and Procedure Status (SNOMED CT) ...... 70 M204080 Finding Scheme in Use ...... 71 M204090 Coded Finding (Coded Clinical Entry)...... 71

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 5 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

Data Group MHS301: Group Session ...... 71 M301010 Group Session Identifier ...... 71 M301020 Group Session Date ...... 71 M301922 Organisation Identifier (Code of Commissioner) ...... 71 M301030 Clinical Contact Duration of Group Session ...... 71 M301040 Group Session Type Code (Mental Health) ...... 71 M301050 Number of Group Session Participants...... 72 M301909 Activity Location Type Code ...... 72 M301921 Organisation Site Identifier (Of Treatment) ...... 74 M301908 Care Professional Local Identifier ...... 74 M301913 Service or Team Type referred to (Mental Health) ...... 74 M301907 NHS Service Agreement Line Number ...... 76 MHS401 Mental Health Act Legal Status ...... 76 M401914 Mental Health Act Legal Status Classification Assignment Period Identifier ...... 76 M401901 Local Patient Identifier (Extended) ...... 76 M401010 Start Date (Mental Health Act Legal Status Classification Assignment Period) ...... 76 M401020 Start Time (Mental Health Act Legal Status Classification Assignment Period) ...... 76 M401030 Mental Health Act Legal Status Classification Assignment Period Start Reason ...... 76 M401040 Expiry Date (Mental Health Act Legal Status Classification Assignment Period) ...... 77 M401050 Expiry Time (Mental Health Act Legal Status Classification Assignment Period) ...... 77 M401060 End Date (Mental Health Act Legal Status Classification Assignment Period) ...... 77 M401070 End Time (Mental Health Act Legal Status Classification Assignment Period) ...... 77 M401080 Mental Health Act Legal Status Classification Assignment Period End Reason ...... 77 M401090 Mental Health Act Legal Status Classification Code ...... 77 M401100 Mental Health Act 2007 Mental Category ...... 79 MHS402 Mental Health Responsible Clinician Assignment ...... 79 M402914 Mental Health Act Legal Status Classification Assignment Period Identifier ...... 79 M402010 Start Date (Mental Health Responsible Clinician Assignment Period) ...... 79 M402908 Care Professional Local Identifier (Extended) ...... 79 M402020 End Date (Mental Health Responsible Clinician Assignment Period) ...... 80 MHS403 Conditional Discharge...... 80 M403914 Mental Health Act Legal Status Classification Assignment Period Identifier ...... 80 M403010 Start Date (Mental Health Conditional Discharge) ...... 80 M403020 End Date (Mental Health Conditional Discharge) ...... 80 M403030 Mental Health Conditional Discharge End Reason ...... 80 M403040 Mental Health Absolute Discharge Responsibility ...... 80 MHS404 Community Treatment Order ...... 80 M404914 Mental Health Act Legal Status Classification Assignment Period Identifier ...... 80 M404010 Start Date (Community Treatment Order)...... 80 M404020 Expiry Date (Community Treatment Order) ...... 81

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 6 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M404030 End Date (Community Treatment Order) ...... 81 M404040 Community Treatment Order End Reason ...... 81 MHS405 Community Treatment Order Recall ...... 81 M405914 Mental Health Act Legal Status Classification Assignment Period Identifier ...... 81 M405010 Start Date (Community Treatment Order Recall) ...... 81 M405020 Start Time (Community Treatment Order Recall) ...... 81 M405030 End Date (Community Treatment Order Recall) ...... 81 M405040 End Time (Community Treatment Order Recall) ...... 81 MHS501 Hospital Provider Spell ...... 81 M501920 Hospital Provider Spell Number ...... 81 M501902 Service Request Identifier ...... 81 M501010 Start Date (Hospital Provider Spell) ...... 82 M501020 Start Time (Hospital Provider Spell) ...... 82 M501030 Source of Admission Code (Hospital Provider Spell) ...... 82 M501040 Admission Method Code (Hospital Provider Spell) ...... 83 M501100 Postcode of Main Visitor ...... 84 M501090 Planned Discharge Date (Hospital Provider Spell) ...... 84 M501150 Planned Discharge Destination Code (Hospital Provider Spell) ...... 84 M501050 Discharge Date (Hospital Provider Spell) ...... 85 M501060 Discharge Time (Hospital Provider Spell) ...... 85 M501070 Discharge Method Code (Hospital Provider Spell) ...... 85 M501080 Discharge Destination Code (Hospital Provider Spell) ...... 86 M501170 Postcode of Discharge Destination (Hospital Provider Spell) ...... 87 MHS502 Ward Stay ...... 87 M502915 Ward Stay Identifier...... 87 M502920 Hospital Provider Spell Number ...... 87 M502010 Start Date (Ward Stay) ...... 87 M502020 Start time (Ward Stay)...... 87 M502030 End Date (Ward Stay) ...... 87 M502040 End Time (Ward Stay)...... 87 M502921 Organisation Site Identifier (Of Treatment) ...... 88 M502050 Ward Setting Type (Mental Health) ...... 88 M502110 Intended Age Group (Mental Health) ...... 88 M502060 Sex of Patients Code ...... 88 M502080 Intended Clinical Care Intensity Code (Mental Health) ...... 89 M502090 Ward Security Level ...... 89 M502100 Locked Ward Indicator ...... 89 M502120 Mental Health Admitted Patient Classification ...... 89 M502140 Ward Code ...... 90 MHS503 Assigned Care Professional ...... 90

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 7 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M503920 Hospital Provider Spell number ...... 90 M503908 Care Professional local identifier ...... 90 M503010 Start Date (Care Professional Admitted Care Episode) ...... 90 M503020 End Date (Care Professional Admitted Care Episode) ...... 90 M503040 Treatment Function Code (Mental Health) ...... 90 MHS504 Mental Health Delayed Discharge ...... 91 M504920 Hospital Provider Spell number ...... 91 M504010 Start Date (Mental Health Delayed Discharge Period) ...... 91 M504020 End Date (Mental Health Delayed Discharge Period) ...... 91 M504030 Mental Health Delayed Discharge Reason ...... 91 M504040 Mental Health Delayed Discharge Attributable to Indication Code ...... 93 MHS505 Restrictive Intervention ...... 93 M505915 Ward Stay Identifier...... 93 M505040 Start Date (Restrictive Intevention) ...... 93 M505020 Start Time (Restrictive Intervention) ...... 93 M505020 Restrictive Intervention Type ...... 93 M505060 End Date (Restrictive Intervention) ...... 94 M505070 End Time (Restrictive Intervention) ...... 94 M505080 Restrictive Intervention Restraint Injury Indicator (Patient)...... 94 M505090 Restrictive Intervention Restraint Injury Indicator (Care Personnel) ...... 94 M505100 Restrictive Intervention Restraint Injury Indicator (Other Person) ...... 94 M505110 Restrictive Intervention Post-Incident Review Held Indicator (Patient) ...... 94 M505120 Restrictive Intervention Post-Incident Review Not Held Reason (Patient) ...... 95 M505130 Restrictive Intervention Post-Incident Review Held Indicator (Care Personnel)...... 95 MHS506 Assault ...... 95 M506915 Ward Stay identifier ...... 95 M506010 Date of assault on patient ...... 95 MHS507 Self Harm ...... 95 M507915 Ward Stay identifier ...... 95 M507010 Date of Self-harm ...... 95 MHS509 Home Leave ...... 95 M509915 Ward Stay identifier ...... 95 M509010 Start Date (Home Leave) ...... 95 M509020 Start Time (Home Leave) ...... 95 M509030 End Date (Home Leave) ...... 96 M509040 End Time (Home Leave) ...... 96 MHS510 Mental Health Leave of Absence ...... 96 M510915 Ward Stay identifier ...... 96 M510010 Start Date (Mental Health Leave of Absence) ...... 96 M510020 Start Time (Mental Health Leave of Absence) ...... 96

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 8 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M510030 End Date (Mental Health Leave of Absence) ...... 96 M510040 End Time (Mental Health Leave of Absence) ...... 96 M510050 Mental Health Leave of Absence End Reason ...... 96 M510060 Escorted Mental Health Leave of Absence Indicator ...... 97 MHS511 Mental Health Absence Without Leave ...... 97 M511915 Ward Stay identifier ...... 97 M511010 Start Date (Mental Health Absence without Leave) ...... 97 M511020 Start Time (Mental Health Absence without Leave) ...... 97 M511030 End Date (Mental Health Absence without Leave) ...... 98 M511040 End Time (Mental Health Absence without Leave) ...... 98 M511050 Mental Health Absence without Leave End Reason ...... 98 MHS512 Hospital Spell Commissioner ...... 98 M512920 Hospital Provider Spell number ...... 98 M512922 Organisation Identifier (Code of Commissioner) ...... 98 M512010 Start Date (Commissioner Assignment Period) ...... 98 M512020 End Date (Commissioner Assignment Period) ...... 99 MHS513 Substance Misuse ...... 99 M513915 Ward Stay Identifier...... 99 M513010 Observation Date (Substance Misuse Evidence) ...... 99 MHS514 Trial Leave ...... 99 M514915 Ward Stay Identifier...... 99 M514010 Start Date (Mental Health Trial Leave) ...... 99 M514020 Start Time (Mental Health Trial Leave) ...... 99 M514030 End Date (Mental Health Trial Leave) ...... 99 M514040 End Time (Mental Health Trial Leave) ...... 99 MHS601 Medical History (Previous Diagnosis) ...... 99 M601901 Local Patient Identifier (Extended) ...... 99 M601913 Diagnosis Scheme in Use ...... 99 M601010 Previous Diagnosis (Coded Clinical Entry) ...... 100 M601916 Diagnosis Date ...... 100 MHS603 Provisional Diagnosis ...... 100 M603902 Service Request Identifier ...... 100 M603913 Diagnosis Scheme In Use ...... 100 M603010 Provisional Diagnosis (Coded Clinical Entry) ...... 100 M603020 Provisional Diagnosis Date ...... 100 MHS604 Primary Diagnosis ...... 101 M604902 Service Request Identifier ...... 101 M604913 Diagnosis Scheme In Use ...... 101 M604010 Primary Diagnosis (Coded Clinical Entry) ...... 101 M604916 Diagnosis Date ...... 101

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 9 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS605 Secondary Diagnosis ...... 101 M605902 Service Request Identifier ...... 101 M605913 Diagnosis Scheme In Use ...... 101 M605010 Secondary Diagnosis (Coded Clinical Entry) ...... 102 M605916 Diagnosis Date ...... 102 MHS606 Coded Scored Assessment (Referral) ...... 102 MHS607 Coded Scored Assessment (Care Activity) ...... 102 M607904 Care Activity Identifier ...... 102 M607910 Coded Assessment Tool Type (SNOMED CT) ...... 102 M607911 Person Score ...... 119 MHS608 Anonymous Self-Assessment ...... 119 MHS701 Care Programme Approach (CPA) Care Episode ...... 119 M701918 Care Programme Approach Care Episode Identifier ...... 119 M701901 Local Patient Identifier (Extended) ...... 119 M701010 Start Date (Care Programme Approach Care) ...... 119 M701020 End Date (Care Programme Approach Care) ...... 119 MHS702 Care Programme Approach Review ...... 119 M702918 Care Programme Approach Care Episode Identifier ...... 119 M702010 Care Programme Approach Review Date ...... 119 M702020 Care Programme Approach Review Abuse Question Asked Indicator ...... 120 M702908 Care Professional Local Identifier ...... 120 MHS801 Clustering Tool ...... 120 M801919 Clustering Tool Assessment Identifier ...... 120 M801901 Local Patient Identifier (Extended) ...... 120 M801010 Clustering Tool Assessment Category...... 120 M801020 Assessment Tool Completion Date ...... 121 M801030 Assessment Tool Completion Time ...... 121 M801040 Clustering Tool Assessment Reason ...... 121 M801060 Mental Health Care Cluster Super Class Code ...... 121 M801050 Adult Mental Health Care Cluster Code (Initial) ...... 121 M801080 Learning Disabilities Care Cluster Code (Initial) ...... 121 M801100 Forensic Learning Disabilities Care Cluster Code (Initial) ...... 122 MHS802 Clustering Assessment ...... 122 M802919 Clustering Tool Assessment Identifier ...... 122 M802910 Coded Assessment Tool Type ...... 122 M802911 Person Score ...... 129 MHS803 Care Cluster ...... 129 M803919 Clustering Tool Assessment Identifier ...... 129 M803020 Start Date (Care Cluster Assignment Period) ...... 129 M803030 Start Time (Care Cluster Assignment Period) ...... 129

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 10 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M803010 Adult Mental Health Care Cluster Code (Final) ...... 129 M803060 Child and Adolescent Mental Health Needs Based Grouping Code ...... 131 M803070 Learning Disabilities Care Cluster Code (Final) ...... 131 M803080 Forensic Mental Health Care Cluster Code (Final) ...... 131 M803090 Forensic Learning Disabilities Care Cluster Code (Final) ...... 132 M803040 End Date (Care Cluster Assignment Period) ...... 132 M803050 End Time (Care Cluster Assignment Period) ...... 132 MHS804 Five Forensic Pathways...... 133 M804901 Local Patient Identifier (Extended) ...... 133 M804010 Five Forensic Pathways Assessment Date...... 133 M804020 Five Forensic Pathways Assessment Reason ...... 133 M804030 Five Forensic Pathways Code ...... 133 MHS901 Staff Details ...... 134 M901908 Care Professional local identifier ...... 134 M901010 Professional Registration Body Code ...... 134 M901020 Professional Registration Entry Identifier ...... 134 M901030 Care Professional Staff Group (Mental Health) ...... 134 M901040 Main Specialty Code (Mental Health) ...... 134 M901050 Occupation Code ...... 134 M901060 Care Professional (Job Role Code) ...... 135

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 11 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

Introduction The purpose of this document is to help your service ensure you are capturing the information on SystmOne required for the Mental Health Services Data Set (MHSDS). Sections which have changed for MHSDS v4 are highlighted red in the contents pages. In this document you will find a description of each data item in the MHSDS and an explanation of the methods used by SystmOne to capture each item. Used in conjunction with F1 Help and the Data Dictionary, it will give you a comprehensive understanding of the contents of the MHSDS, and will help guide your service to initialise and sustain the production of an accurate extract. Important: The MHSDS data set contains patient identifiable data (NHS number, date of birth, patients’ postcode) in addition to safeguarding and child protection information. It is the trust/service’s responsibility to ensure that only appropriate users are allowed to run the MHSDS extract on SystmOne. The Run Reports - can access and run clinical and administrative reports SystmOne access right is required to run the MHSDS extract. The following sections explain how the information required to populate the MHSDS data extract is recorded in SystmOne.

Including patients in the MHSDS extract All patients with an active period of care at the organisation running the extract (i.. an active registration) will be included in the MHSDS.

Excluding patients from the MHSDS extract Where a patient explicitly objects to their data being used for secondary purposes, the provider has the option of not flowing the records for this patient into the MHSDS, as directed by their local Caldicott Guardian. To achieve this in SystmOne, the user must record the CTV3 Read code ‘XaaVL - Dissent from disclosure of personal confidential data HSCIC’ on the patient record. TPP recommend, before running the MHSDS extract, a Clinical Report is run to show all patients that have the ‘XaaVL - Dissent from disclosure of personal confidential data HSCIC’ code recorded on their record. These patients can be reviewed on a case by case basis to ensure that it is correct that their data is not being flowed into the extract. Additionally, if a patient later consents to flowing their data into the extract, recording the CTV3 Read code ‘XaaVM - Dissent withdrawn disclosure personal confidential dta HSCIC’ will ensure their data is flowed into the extract. In each case, the most recently recorded CTV3 Read code (‘XaaVL - Dissent from disclosure of personal confidential data HSCIC’ or ‘XaaVM - Dissent withdrawn disclosure personal confidential dta HSCIC’) is what will dictate whether the patient’s data flows into the extract or not.

MHS000 MHSDS Header

M000010 Data Set Version Number The version of the MHSDS data that this submission file is for.

M000080 Organisation Identifier (code of provider) The organisation identifier of the organisation that is acting as the Health Care Provider. This is automatically output as the organisation code for the NHS Trust or Provider the organisation belongs to.

M000090 Organisation Identifier (code of submitting organisation) The organisation identifier of the organisation that is submitting the data. This is automatically output as the organisation code for the NHS Trust or Provider the organisation belongs to.

M000040 Primary Data Collection System In Use The Primary Data Collection System in use by the Health Care Provider is SystmOne.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 12 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M000050 Reporting Period Start Date The reporting period start date to which this file refers to.

M000060 Reporting Period End Date The reporting period end date to which this file refers to.

M000070 Date and Time Data Set Created The time and date that the upload file was created. MHS001 Master Patient Index

M001901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M001170 Organisation Identifier (local patient identifier) The identifier of the organisation that assigned the local patient identifier. This is automatically output as the organisation code for the NHS Trust or Provider the organisation belongs to.

M001180 Organisation Identifier (residence responsibility) SystmOne automatically extracts this information based on the patient’s postcode of usual address.

M001190 Organisation Identifier (educational establishment) SystmOne automatically extracts this information when the patient’s school has been recorded. A school can be added to the patient’s record by right-clicking on the Schools node, and selecting New School.

M001040 NHS Number A number used to identify a patient uniquely within the NHS in England and Wales. In SystmOne the NHS number of a patient can be added in the Security Controlled Procedures dialog.

M001050 NHS Number Status Indicator Code This is the status of the NHS number and is captured automatically. SystmOne will produce one of four codes:

National Code Description

01 NHS number present and verified

02 Number present but not traced

03 Trace required

08 Trace postponed (no NHS number, baby under six weeks old)

M001060 Person Birth Date This is recorded as part of patient registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details.

M001070 Postcode of Usual Address This is the postcode of the address that was active when the attendance occurred.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 13 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M001090 Person Stated Gender Code This is the current gender as declared by the person, or inferred by observation for those unable to declare their person stated gender. This is recorded as part of patient registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details.

National Code Description

1 Male

2 Female

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

X Not known (person stated gender not recorded)

M001150 Person Marital Status An indicator to identify the legal marital status of a person. This is recorded as part of patient registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code

S Single Single person (XE0oZ)

M Married/Civil Partner Married/civil partner (XaMz3) Married/Civil Partner (Y0673)

D Divorced/Person whose Civil Partnership Divorced/person whose civil partnership has has been dissolved been dissolved (XaMz4) Divorced/Person whose Civil Partnership has been dissolved (Y0674)

W Widowed/Surviving Civil Partner Widowed/surviving civil partner (XaMz6) Widowed/Surviving Civil Partner (Y0675)

P Separated Separated (XE0ob) and children

N Not disclosed Marital/civil state not disclosed (XaMz7)

8 Not applicable, i.e. not a psychiatric episode No Read code available

9 Not known Marital state unknown (133F.)

M001100 Ethnic Category The ethnicity of the person as specified by the person. This is recorded as part of patient registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code

A White – British White British - ethnic category 2001 census (XaQEa)

B White – Irish White Irish - ethnic category 2001 census (XaQEb)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 14 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code

C White – Any other White background Other White background - ethnic category 2001 census (XaJQx)

D Mixed – White and Black Caribbean White and Black Caribbean- ethnic category 2001 census (XaJQy)

E Mixed – White and Black African White and Black African - ethnic category 2001 census (XaJQz)

F Mixed – White and Asian White and Asian - ethnic category 2001 census (XaJR0)

G Mixed – Any other Mixed background (Other Mixed background - ethnic category 2001 census) XaJR1

H Asian or Asian British – Indian Indian or British Indian - ethnic category 2001 census (XaJR2)

J Asian or Asian British – Pakistani Pakistani or British Pakistani - ethnic category 2001 census (XaJR3)

K Asian or Asian British – Bangladeshi Bangladeshi or British Bangladeshi - ethn categ 2001 census (XaJR4)

L Asian or Asian British – Any other Asian background Other Asian background - ethnic category 2001 census (XaJR5)

M Black or Black British – Caribbean Caribbean - ethnic category 2001 census (XaJR6)

N Black or Black British – African African - ethnic category 2001 census (XaJR7)

P Black or Black British – Any other Black background Other Black background - ethnic category 2001 census (XaJR8)

R Other Ethnic Groups – Chinese Chinese - ethnic category 2001 census (XaJR9)

S Other Ethnic Groups – Any other ethnic group Other - ethnic category 2001 census (XaJRA)

Z Other Ethnic Groups – Not stated Ethnic category not stated - 2001 census (XaJRB)

99 Other Ethnic Groups – Not known No Read code recorded in Patient>Patient Maintenance>Patient Details

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 15 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M001120 Language Code (Preferred) The language that the patient prefers to use for communication with the Health Care Provider. This is recorded as part of patient registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code (ISO 639-1)

aa Afar Main spoken language Afar (XaPF9)

ab Abkhazian Main spoken language Abkhaz (XaPF8)

af Main spoken language Afrikaans (XaPFA)

ak Akan Main spoken language Akan (XaJOq)

sq Albanian Main spoken language Albanian (XaJDK)

am Amharic Main spoken language Amharic (XaJOr)

ar Main spoken language Arabic (XaG5p)

an Aragonese Main spoken language Aragonese (XaYWG)

hy Armenian Main spoken language Armenian (XaPFB)

as Assamese Main spoken language Assamese (XaPFC)

av Avaric Avar language (Xa6d8)

ae Avestan Main spoken language Avestan (Y15da)

ay Aymara Main spoken language Aymara (XaPFD)

az Azerbaijani Main spoken language Azerbaijani (XaPFF)

ba Bashkir Main spoken language Bashkir (XaPFG)

bm Bambara Bambara language (Xa6im)

eu Basque Main spoken language Basque (XaPFH)

be Belarusian Main spoken language Belarusian (XaPFO)

bn Bengali Main spoken language Bengali (XaG5q)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 16 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

bh Bihari Main spoken language Bihari (XaPFK)

bi Bislama Main spoken language Bislama (XaPFL)

bo Tibetan Main spoken language Tibetan (XaPGS)

bs Bosnian Main spoken language Bosnian (Y15db)

br Breton Main spoken language Breton (XaPFM)

bg Bulgarian Main spoken language Bulgarian (XaP48)

my Burmese Main spoken language Burmese (XaPFN)

ca Catalan; Valencian Main spoken language Catalan (XaPFQ); Main spoken language Valencian (Y15dc)

cs Czech Main spoken language Czech (XaG5s)

ch Chamorro Chamorro language (Xa6gM)

ce Chechen Chechen language (Xa6dE)

zh Chinese (Xa6lB)

cu Church Slavic; Old Slavic; Church Slavonic; Old Bulgarian; Main spoken language Old Old Church Slavonic Slavonic (Y15dd)

cv Chuvash Chuvash language (Xa6cb)

kw Cornish Main spoken language Cornish (Y15de)

co Corsican Main spoken language Corsican (XaPFT)

cr Cree Cree language (Xa6j9)

cy Welsh Main spoken language Welsh (XaJPD)

da Danish Main spoken language Danish (XaPFU)

de German Main spoken language German (XaJD6)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 17 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

dv Divehi; Dhivehi; Maldivian Main spoken language Divehi (Y15df), Maldivian language (Xa6fk)

nl Dutch; Flemish Main spoken language Dutch (XaJOt); Main spoken language Flemish (XaJOv)

dz Dzongkha Main spoken language Dzongkha (XaPFI)

el Greek, Modern (1453-) Main spoken language Greek (XaJDM)

en English Main spoken language English (XaG5t)

eo Esperanto Main spoken language Esperanto (XaPFV)

et Estonian Main spoken language Estonian (XaPFW)

ee Ewe Ewe language (Xa6iZ)

fo Faroese Faroese language (Xa6eo)

fa Persian Main spoken language Farsi (XaIpr); Persian language (Xa6g5)

fj Fijian Main spoken language Fijian (XaPFZ)

fi Finnish Main spoken language Finnish (XaKIL)

fr French Main spoken language French (XaG5u)

fy Western Frisian Main spoken language Western Frisian (Y15e0)

ff Fulah Main spoken language Fulah (Y15e1)

ka Georgian Main spoken language Georgian (XaPFe)

gd Gaelic; Scottish Gaelic Scottish Gaelic language (Xa6ek)

ga Irish Main spoken language Irish (XaPFo)

gl Galician Main spoken language Galician (XaPFd)

gv Manx Main spoken language Manx (Y15e2)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 18 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

gn Guarani Main spoken language Guarani (XaPFg)

gu Gujarati Main spoken language Gujarati (XaG5v)

ht Haitian; Haitian Creole Main spoken language Haitian (Y15e3)

ha Hausa Main spoken language Hausa (XaG5w)

he Hebrew Main spoken language Hebrew (XaJOz)

hz Herero (Xa6hc)

hi Main spoken language Hindi (XaG5x)

ho Hiri Motu Motu language (Xa6gm); Police Motu language (Xa6l1)

hr Croatian Main spoken language Croatian (XaJDL)

hu Hungarian Main spoken language Hungarian (XaPFh)

hy Armenian Main spoken language Armenian (XaPFB)

ig Igbo Main spoken language Igbo (XaJP0)

is Icelandic Main spoken language Icelandic (XaPFi)

io Ido Main spoken language Ido (Y15e4)

ii Sichuan Yi; Nuoso Main spoken language Sichuan Yi (Y15e5)

iu Inuktitut Main spoken language Inuktitut (XaPFn)

ie Interlingue; Occidental Main spoken language Interlingue (XaPFl); Occidental (Xa6d2)

ia Interlingua (International Auxiliary Language Association) Main spoken language Interlingua (XaPFk)

id Indonesian Main spoken language Indonesian (XaPFj)

ik Inupiaq Main spoken language Inupiaq (XaPFm)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 19 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

it Italian Main spoken language Italian (XaJD5)

jv Javanese Main spoken language Javanese (XaPFp)

ja Japanese Main spoken language Japanese (XaJDN)

kl Kalaallisut; Greenlandic Main spoken language Kalaallisut (XaPFf)

kn Kannada Main spoken language Kannada (XaPFq)

Kashmiri Main spoken language Kashmiri (XaPFr)

kr Kanuri Kanuri language (Xa6l5)

kk Kazakh Main spoken language Kazakh (XaPFs)

km Central Khmer Main spoken language Central Khmer (XaPFP)

ki Kikuyu; Gikuyu Main spoken language Kikuyu (XaWQU); Main spoken language Kikuyu (Y15e6)

rw Main spoken language Kinyarwanda (XaPFt)

ky Kirghiz; Kyrgyz Main spoken language Kirghiz (XaPFu)

kv Komi Komi language (Xa6lr)

kg Kongo (Xa6hg)

ko Korean Main spoken language Korean (XaJDO)

kj Kuanyama; Kwanyama Main spoken language Kuanyama (Y15e7)

ku Kurdish Main spoken language Kurdish (XaIps)

lo Lao Main spoken language Lao (XaPFw)

la Latin Latin language (Xa6f4)

lv Latvian Main spoken language Latvian (XaPFy)

li Limburgan; Limburger; Main spoken language Limburgan (Y15e8)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 20 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

ln Main spoken language Lingala (XaJP1)

lt Lithuanian Main spoken language Lithuanian (XaJDP)

lb ; Letzeburgesch Luxembourgian language (Xa6ez)

lu Luba - Katanga Main spoken language Luba – Katanga (Y15e9)

lg Ganda Ganda language (Xa6hZ)

mk Macedonian Main spoken language Macedonian (XaPFz)

mh Marshallese Marshallese language (Xa6gf)

ml Malayalam Main spoken language Malayalam (XaJP3)

mi Maori Main spoken language Maori (XaPG3)

mr Marathi Main spoken language Marathi (XaPG4)

ms Malay Main spoken language Malay (XaPG1)

mg Malagasy Main spoken language Malagasy (XaPG0)

mt Maltese Main spoken language Maltese (XaPG2)

mn Mongolian Main spoken language Mongolian (XaPG6)

na Nauru Main spoken language Nauru (XaPG7)

nv Navajo; Navaho Navajo language (Xa6jL)

nr Ndebele, South; South Ndebele Main spoken language South Ndebele (Y15ea)

nd Ndebele, North; North Ndebele Main spoken language North Ndebele (Y15eb)

ng Ndonga Main spoken language Ndonga (Y15ec)

ne Nepali Main spoken language Nepali (XaPG8

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 21 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

nn Norwegian ; Nynorsk, Norwegian Main spoken language Norwegian Nynorsk (Y15ed)

nb Bokmål Norwegian; Norwegian Bokmål Main Spoken Language Norwegian Bokmål (Y15ee)

no Norwegian Main spoken language Norwegian (XaJP4)

ny Chichewa; Chewa; Nyanja Main language spoken Chewa (Y0cf9); Main spoken language Nyanja (XaWQW)

oc Occitan (post 1500) Main spoken language Occitan (XaPG9)

oj Ojibwa Ojibwa language (Xa6jE)

or Oriya Main spoken language Oriya (XaPGA)

om Oromo Main spoken language Oromo (XaPF7)

Ossetian; Ossetic Ossetian language (Xa6g3)

pa Panjabi; Punjabi Main spoken language Punjabi (XaG63)

pi Pali Main Spoken Language Pali (Y15ef)

pl Polish Main spoken language Polish (XaG61)

pt Portuguese Main spoken language Portuguese (XaG62)

Pashto; Pushto Main spoken language Pashto (XaJP5)

qu Quechua Main spoken language Quechua (XaPGC)

rm Romansh Main spoken language Romansh (XaPGD)

ro Romanian; Moldavian; Moldovan Main spoken language Romanian (XaP49); Main spoken language Moldavian (XaPG5)

rn Rundi Main spoken language Rundi (XaPFv)

ru Russian Main spoken language Russian (XaG64)

sg Sango Main spoken language Sango (XaPGF)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 22 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

sa Sanskrit Sanskrit language (Xa6fu)

si Sinhala; Sinhalese Main spoken language Sinhala (XaJP8); Sinhalese language (Xa6fw)

sk Slovak Main spoken language Slovak (XaP9z)

sl Slovenian Main spoken language Slovenian (XaPGN)

se Northern Sami Main Spoken Language Northern Sami (Y15f0)

sm Samoan Main spoken language Samoan (XaPGE)

sn Shona Main spoken language Shona (XaIpt)

sd Sindhi Main spoken language Sindhi (XaPGK)

so Somali Main spoken language Somali (XaG65)

st Sotho, Southern Main spoken language Southern Sotho (XaPGI)

Spanish; Castilian Main spoken language Spanish (XaG66)

sc Sardinian Sardinian language (Xa6fG)

sr Serbian Main spoken language Serbian (XaJP7)

Swati Main spoken language Swati (XaPGM)

su Sundanese Main spoken language Sundanese (XaPGO)

sw Swahili Main spoken language Swahili (XaG67)

sv Swedish Main spoken language Swedish (XaJP9)

ty Tahitian Tahitian language (Xa6gw)

ta Tamil Main spoken language Tamil (XaG69)

tt Tatar Main spoken language Tatar (XaPGQ)

te Telugu Main spoken language Telugu (XaPGR)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 23 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

tg Tajik Main spoken language Telugu (XaPGP)

tl Tagalog Main spoken language Tagalog (XaJPA)

th Thai Main spoken language Thai (XaJPB)

ti Tigrinya Main spoken language Tigrinya (XaJPC)

to Tonga (Tonga Islands) Main spoken language Tongan (XaPGT)

tn Tswana Main spoken language Tswana (XaPGJ)

ts Tsonga Main spoken language Tsonga (XaPGU)

tk Turkmen Main spoken language Turkmen (XaPGV)

tr Turkish Main spoken language Turkish (XaJDQ)

tw Twi Main spoken language Twi (XaPGW)

ug Uighur; Uyghur Main spoken language Uighur (XaPGX)

uk Ukrainian Main spoken language Ukrainian (XaJDR)

ur Urdu Main spoken language Urdu (XaG6A)

uz Uzbek Main spoken language Uzbek (XaPGY)

ve Venda (Xa6iC)

vi Vietnamese Main spoken language Vietnamese (XaJDS)

vo Volapük Main Spoken Language Volapük (Y15f1)

wa Walloon Main spoken language Walloon (Y15f2)

wo Wolof Main spoken language Wolof (XaPGa)

xh Xhosa Main spoken language Xhosa (XaPGb)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 24 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code (ISO 639-1)

yi Main spoken language Yiddish (XaPGc)

yo Yoruba Main spoken language Yoruba (XaG6B)

za Zhuang; Chuang Main spoken language Zhuang (XaPGd); Chuang language (Xa6lM)

zu Zulu Main spoken language Zulu (XaPGe)

Extensions

q1 Braille (for people who are unable to see) Reads Braille (XaLUo)

q2 American American sign language (Y07d0)

q3 Australian Sign Language Australian sign language (Y07d1)

q4 British Sign Language Preferred method of communication: British Sign Language (XaR7A)

q5 Makaton (devised for children and adults with a variety of Preferred method of communication and learning disabilities) communication: Makaton (XaR76)

M001130 Person Death Date This is recorded in the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details. MHS002 GP Practice Registration

M002901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M002010 General Medical Practice Code (Patient Registration) The organisation code of the GP Practice that the patient is registered with. SystmOne automatically extracts this information, based on the patient’s registered GP. If the patient has never had a registered GP, we will populate this with code V81999.

M002020 Start Date (GMP Patient Registration) Start Date on which the person registered with a General Medical Practitioner Practice. SystmOne automatically extracts this information.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 25 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M002030 End Date (GMP Patient Registration) End Date on which the person registered with a General Medical Practitioner Practice. SystmOne automatically extracts this information when the end date is within the reporting period.

M002050 Organisation Identifier (GP Practice Responsibility) This is the organisation identifier of the organisation responsible for the GP Practice where the patient is registered, i.e. the Clinical Commissioning Group (CCG), irrespective of whether they reside within the boundary of the CCG. SystmOne automatically extracts the CCG organisation code, based on the patient’s registered GP.

MHS003 Accommodation Status

M003901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M003010 Accommodation Status Code An indication of the type of accommodation that a patient currently has, based on the patient's main or permanent residence. This can be recorded in the Accommodation Status field on the Social Inclusion node or on the CPA Level Assessment dialog.

National Code Extract Description SystmOne Configured List Option

MA00 Mainstream Housing Mainstream Housing

MA01 Owner occupier Owner occupier

MA02 Settled mainstream housing with Settled mainstream housing with family/friends family/friends

MA03 Shared ownership scheme e.. Social Shared ownership scheme Homebuy Scheme (tenant purchase percentage of home value from landlord)

MA04 Tenant - Local Authority/Arms Length Tenant - Local Authority/Arms Length Management Organisation/Registered Management Organisation/Registered Landlord Landlord

MA05 Tenant - Housing Association Tenant - Housing Association

MA06 Tenant - private landlord Tenant - private landlord

MA09 Other mainstream housing Other mainstream housing

HM00 Homeless Homeless

HM01 Rough sleeper Rough sleeper

HM02 Squatting Squatting

HM03 Night shelter/emergency hostel/Direct Night shelter/emergency hostel/Direct access hostel (temporary access hostel accommodation accepting self referrals, no waiting list and relatively frequent vacancies)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 26 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

HM04 Sofa surfing (sleeps on different friends Sofa surfing (sleeps on different friends floor each night) floor each night)

HM05 Placed in temporary accommodation by Placed in temporary accommodation by Local Authority (including Local Authority (including Homelessness Homelessness resettlement service) resettlement service) e.g. Bed and Breakfast accommodation

HM06 Staying with friends/family as a short Staying with friends/family as a short term term guest guest

HM07 Other homeless Other homeless

MH00 Accommodation with mental health care Accommodation with mental health care support support

MH01 Supported accommodation Supported accommodation (accommodation supported by staff or (accommodation supported by staff or resident caretaker) resident caretaker)

MH02 Supported lodgings (lodgings supported Supported lodgings (lodgings supported by by staff or resident caretaker) staff or resident caretaker)

MH03 Supported group home (supported by Supported group home (supported by staff staff or resident caretaker) or resident caretaker)

MH04 Mental Health Registered Care Home Mental Health Registered Care Home

MH09 Other accommodation with mental Other accommodation with mental health health care and support care and support

HS00 Acute/long stay healthcare residential Acute/long stay healthcare residential facility/hospital facility/hospital

HS01 NHS acute psychiatric ward NHS acute psychiatric ward

HS02 Independent hospital/clinic Independent hospital/clinic

HS03 Specialist rehabilitation/recovery Specialist rehabilitation/recovery

HS04 Secure psychiatric unit Secure psychiatric unit

HS05 Other NHS facilities/hospital Other NHS facilities/hospital

HS09 Other acute/long stay healthcare Other Acute/long stay healthcare residential residential facility/hospital facility/hospital

CH00 Accommodation with other (not Accommodation with other (not specialist specialist mental health) care support mental health) care support

CH01 Foyer - accommodation for young Foyer - accommodation for young people people aged 16-25 who are homeless aged 16-25 who are homeless or in housing or in housing need need

CH02 Refuge Refuge

CH03 Non-Mental Health Registered Care Non-Mental Health Registered Care Home Home

CH09 Other accommodation with care and Other accommodation with care and support (not specialist mental health) support (not specialist mental health)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 27 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

CJ00 Accommodation with criminal justice Accommodation with criminal justice support support

CJ01 Bail/Probation hostel Bail/Probation hostel

CJ02 Prison Prison

CJ03 Young Offenders Institute Young Offenders Institution

CJ04 Detention Centre Detention Centre

CJ05 Young Offender Institution (15-17) Young Offender Institution (15-17)

CJ06 Young Offender Institution (18-21) Young Offender Institution (18-21)

CJ07 Secure Children's Home (Secure Secure Children's Home (Secure Welfare Welfare Accommodation only) Accommodation only)

CJ08 Secure Children's Home (Youth Secure Children's Home (Youth Detention Detention Accommodation only) Accommodation only)

CJ10 Secure Children's Home (Secure Secure Children's Home (Secure Welfare Welfare Accommodation and Youth Accommodation and Youth Detention Detention Accommodation) Accommodation)

CJ11 Secure Training Centre Secure Training Centre

CJ12 Other accommodation with criminal Other accommodation with criminal justice justice support support

SH00 Sheltered Housing (accommodation Sheltered Housing with a scheme manager or warden living on the premises or nearby, contactable by an alarm system if necessary)

SH01 Sheltered housing for older persons Sheltered housing for older persons

SH02 Extra care sheltered housing (also Extra care sheltered housing known as 'very sheltered housing'. For people who are less able to manage on their own, but who do need an extra level of care. Services offered vary between schemes, but meals and some personal care are often provided.)

SH03 Nursing Home for older persons Nursing Home for older persons

SH09 Other sheltered housing Other sheltered housing

ML00 Mobile accommodation Mobile accommodation

Other

OC96 Not elsewhere classified Not elsewhere classified

OC97 Not specified Not specified

OC98 Not applicable Not applicable

OC99 Not known Not known

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 28 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M003020 Settled Accommodation Indicator An indication of whether the patient is in settled accommodation. This is recorded in the Settled Accommodation Indicator field on the Social Inclusion node or on the CPA Level Assessment dialog.

National Code Extract Description SystmOne Configured List Option

N No - Non-settled Accommodation Non-settled

Y Yes – Settled Accommodation Settled

Z Not Stated (PERSON asked but Not disclosed declined to provide a response)

9 Not Known Not Known

M003030 Accommodation Status Recorded Date The date an Accommodation Status Code was recorded. SystmOne will automatically extract this item.

M003040 Secure Children’s Home Placement Type Defined in the NHS Data Dictionary as “The type of placement for a Child or Young Person accommodated in a Secure Children’s Home”. This can be recorded in the field “Secure Children’s Home Placement Type” on the Social Inclusion dialog from the Social Inclusion node in the patient record. This field is also available when amending a CPA Review. This field will only display when an accommodation status of Secure Children’s Homehas been selected (national codes CJ07, CJ08 or CJ10).

National Code Extract Description SystmOne Configured List Option Secure welfare placement 1 Secure welfare placement

2 Youth justice placement Youth justice placement

MHS004 Employment Status This table only applies to patients aged 18 to 69, as specified in the NHS Digital MHSDS User Guidance V3.0.

M004901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 29 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M004010 Employment Status The employment status of the patient at the time of their latest assessment or review before the end of the reporting period. In SystmOne this is recorded in the Social Inclusion dialog, accessed from the Social Inclusion node, or when doing a CPA review.

National Code Extract Description SystmOne Configured List Option

01 Employed Employed

02 Unemployed and Seeking Work Unemployed and Seeking Work

03 Students who are undertaking full (at Students who are not working or actively least 16 hours per week) or part-time seeking work (less than 16 hours per week) education or training and who are not working or actively seeking work

04 Long-term sick or disabled, those who Long-term sick or disabled, those who are are receiving Incapacity Benefit, Income receiving benefits Support or both; or Employment and Support Allowance

05 Homemaker looking after the family or Homemaker looking after the family or home and who are not working or home and who are not working or actively actively seeking work seeking work

06 Not receiving benefits and who are not Not receiving benefits and who are not working or actively seeking work working or actively seeking work

07 Unpaid voluntary work who are not Unpaid voluntary work who are not working working or actively seeking work or actively seeking work

08 Retired Retired

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

M004020 Employment Status Recorded Date The date an Employment Status Code was recorded. SystmOne will automatically extract this item.

M004030 Weekly Hours Worked This is the number of hours worked in a typical week. This is recorded in the Weekly hours worked field on the Social Inclusion dialog, which can be accessed by right clicking on the Social Inclusion node and selecting Record Social Inclusion Information. This is also recorded in the Weekly hours worked field on the CPA Review dialog when right clicking on a CPA and selecting Record Review.

National Code Extract Description SystmOne Configured List Option

01 30+ hours 30 + hours

02 16-29 hours 16-29 hours

03 5-15 hours 5-15 hours

04 1-4 hours 1-4 hours

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

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 30 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

98 Not applicable (PATIENT not employed) Not applicable (PATIENT not employed)

99 Number of hours worked not known Number of hours worked not known

MHS005 Patient Indicators

M005901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M005010 Constant Supervision and Care Required Due to Disability Indicator An indicator of whether the patient needs constant supervision and care. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code

Y Yes (Person requires round the clock care Constant care and supervision required and/or supervision) (Disability indicator) (Y15bd)

N No (person does not require round the clock Absence of Y15bd care and/or supervision) Constant care and supervision not required (Disability indicator) (Y16b5)

M005020 Young Carer Indicator An indicator of whether the patient is a young carer. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code

Y Yes – child or young PERSON has a caring role Is a Young Carer (Y12ad) for an ill or disabled parent, carer or sibling

N No – child or young PERSON does not have a Is not a Young Carer (Y12ae) caring role for an ill or disabled parent, carer or sibling

Z Not Stated (Person asked but declined to Young Carer Status - Not stated (Y12b0) provide a response)

X Not Known Young Carer Status - Unknown (Y12af)

M005030 Looked After Child Indicator An indicator of whether the patient is a looked after child. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code

Y Yes (Is a Looked After Child) Looked after child (XaXLt)

N No (Is not a Looked After Child) Absence of XaXLt or when the patient has XaXLt with a later code of Child no longer looked after (Y04b5)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 31 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M005040 Child Protection Plan Indication Code An indication of whether the patient is/has previously been subject to a child protection plan. This will be recorded using the Safeguarding Information node.

National Code Extract Description SystmOne Option

1 Has never been subject to a Child Protection The 'Patient is currently on child Plan protection plan' tick box has never been ticked.

2 Has previously been subject to a Child In the Safeguarding Information node, the Protection Plan 'Patient is currently on child protection plan' tick box is ticked and then unticked.

3 Is currently subject to a Child Protection Plan In the Safeguarding Information node, the 'Patient is currently on child protection plan' tick box is ticked.

M005100 Ex-British Armed Forces Indicator An indication of whether the person 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. This will be recorded using CTV3 Read codes. If no relevant Read code is recorded, the output will be blank.

National Code Extract Description SystmOne Read code

02 Ex-services member Served in armed forces (Ua0T3) Military veteran (XaX3N) and children

03 Not an ex-services member or their dependant Not an ex-services member or their dependant (MHSDS) (Y180d)

05 Dependant of an ex-services member Dependant of an ex-services member (MHSDS) (Y180e)

UU Unknown (Person asked and does not know or Armed forces history unknown (MHSDS) is not sure) (Y180f)

ZZ Not stated (Person asked but declined to Armed forces history not stated (MHSDS) provide a response) (Y181a)

M005110 Offence History Indication Code An indication of whether the person 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. This will be recorded using CTV3 Read codes. If there is no relevant Read code recorded, the code for “Not Known” will be output in the MHSDS.

National Code Extract Description SystmOne Read code

1 No - No offence Offence history (MHSDS) – None (Y17ff)

2 Yes - Less serious offence Offence history (MHSDS) - Less Serious (Y180a)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 32 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code

3 Yes - Serious offence Offence history (MHSDS) – Serious (Y180b)

X Not Known Offence history (MHSDS) - Not known (Y180c)

M005120 Parental responsibilities indicator This is an indication of whether the patient has Parental Responsibilities for a child or young person, as stated by the patient. This will be recorded using CTV3 Read Codes.

National Code Extract Description SystmOne Read code

Y Yes – PERSON has parental responsibilities for Person has responsibilities for a child or a child or young PERSON young person (Y1eea) - Y

N No – PERSON does not have parental Person does not have responsibilities for responsibilities for a child or young PERSON a child or young person (Y1eeb) - N

Z Not Stated (PERSON asked but declined to Parental Responsibilities for this person - provide a response) Not stated (Y1eec) - Z

X Not Known (not recorded) Parental Responsibilities for this person - Not known (Y1eed) - X

M005050 Prodrome Psychosis Date This is the date which the first noticeable change in behavior or mental state occurred prior to emergence of full- blown psychosis for the patient. This will be recorded using the CTV3 Read code Date Prodrome Psychosis Read code (Y158a).

M005060 Emergent Psychosis Date This is the date which there was first clear evidence of a positive psychotic symptom for the patient regardless of its duration. This will be recorded using the CTV3 Read code Emergent Psychosis (Y158b).

M005070 Manifest Psychosis Date This is the date which a positive psychotic symptom has lasted for a week for the patient. This is usually 7 days after the date of the first psychotic symptom. This will be recorded using the CTV3 Read code Manifest Psychosis (Y158c).

M005080 First Prescription Date (Anti-psychotic medication) This is the date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP). This will be recorded using the CTV3 Read code Anti-psychotic medication prescribed (Y158d). This will be automatically extracted where a patient is referred to the configured list option Team Type of Early Intervention in Psychosis (MHSDS mapped code A14) and the CTV3 Read code Anti- psychotic medication prescribed (Y158d) is recorded for the first time.

M005090 Psychosis First Treatment Start Date This is the date the patient first commenced prescribed anti-psychotic medication, following referral into an Early Intervention in Psychosis (EIP). This is the date the Read code Y158e - Psychosis drug treatment started is

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 33 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

added after a referral has been added in the patient record that is for a team that has a Team Type of Early Intervention in Psychosis – (National Code A14). If the patient has had code Y158e added to their record multiple times, the first date it was added after the referral will be extracted in to the MHSDS.

MHS006 Mental Health Care Coordinator

M006901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M006010 Start Date (Mental Health Care Coordinator Assignment Period) This is the date the Care Coordinator period for the patient was added. In SystmOne this is the start date when recording a Care Coordinator, in the Responsibilities node.

M006908 Care Professional Local Identifier This number uniquely identifies the care professional within the Health Care Provider system. SystmOne will extract this information automatically.

M006030 End Date (Mental Health Care Coordinator Assignment Period) This is the date the Care Coordinator period for the patient ended. In SystmOne this is the end date when recording a Care Coordinator, in the Responsibilities node.

M006040 Care Professional Service or Team Type Association (Mental Health) This is the type of team that the assigned Care Co-ordinator is working on behalf of. In SystmOne, this is recorded when recording a Care Co-ordinator and selecting a team that is mapped to a team type national code in the Responsibilities node.

National Code Extract Description SystmOne Configured List Option

General Mental Health Services

A01 Day Care Service Day Care Service

A02 Crisis Resolution Team/Home Treatment Crisis Resolution Team/Home Treatment Service Service

A03 Crisis Resolution Team Crisis Resolution Team

A04 Home Treatment Service Home Treatment Service

A05 Primary Care Mental Health Service Primary Care Mental Health Service

A06 Community Mental Health Team – Functional Community Mental Health Team – Functional

A07 Community Mental Health Team – Organic Community Mental Health Team – Organic

A08 Assertive Outreach Team Assertive Outreach Team

A09 Rehabilitation & Recovery Service Rehabilitation & Recovery Service

A10 General Psychiatric Service General Psychiatric Service

A11 Psychiatric Liaison Service Psychiatric Liaison Service

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 34 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

A12 Psychotherapy Service Psychotherapy Service

A13 Psychological Therapy Service (non IAPT) Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis Early Intervention Team for Psychosis

A15 Young Onset Dementia Team Young Onset Dementia Team

A16 Personality Disorder Service Personality Disorder Service

A17 Memory Services/Clinic Memory Services/Clinic

A18 Single Point of Access Service Single Point of Access Service

A19 24/7 Crisis Response Line 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service Health Based Place Of Safety Service

Forensic Services

B01 Forensic Mental Health Service Forensic Mental Health Service

B02 Forensic Learning Disability Service Forensic Learning Disability Service

Specialist Mental Health Services

C01 Autistic Spectrum Disorder Service Autistic Spectrum Disorder Service

C02 Peri-Natal Mental Illness Service Peri-Natal Mental Illness Service

C03 Eating Disorders/Dietetics Service Eating Disorders/Dietetics Service

C04 Neurodevelopment Team Neurodevelopment Team

C05 Paediatric Liaison Service Paediatric Liaison Service

C06 Looked After Children Service Looked After Children Service

C07 Community Young Offenders Service Community Young Offenders Service

C08 Acquired Brain Injury Service Acquired Brain Injury Service

C09 Community Eating-Disorder Service for Children Community Eating-Disorder Service for and Young People Children and Young People

Other Mental Health Services

D01 Substance Misuse Team Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service Prison Psychiatric Inreach Service

D04 Asylum Service Asylum Service

D05 Individual Placement and Support Service Individual Placement and Support Service

Learning Disability Services

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 35 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

E01 Community Team for Learning Disabilities Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service Epilepsy/Neurological Service

E03 Specialist Parenting Service Specialist Parenting Service

E04 Enhanced/Intensive Support Service Enhanced/Intensive Support Service

Other

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

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

MHS007 Disability Type

M007901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M007010 Disability code This is an indication of whether a person is disabled. This can be recorded using the below CTV3 Read codes. N.. if users record one of the codes for Disability Impact Perception (see Disability Impact Perception section below), this will extract the relevant national code for both the Disability Impact Perception and Disability Code data items.

National Code Extract Description SystmOne Read code

01 Behaviour and Emotional Codes under Behavioural disability (Xa1ai)

02 Hearing Codes under Ear anomalies with hearing impairment (P40..); /: impaired hearing (XaXeh); Hearing for conversational voice impaired (Xa7SL); Unable to hear conversational voice (XaAw5); Hearing for loud voice impaired (Xa7SN); Hearing for voice impaired (Xa7SP); Hearing for whisper impaired (Xa7SJ); codes under Hearing loss (XE0s9), Impaired hearing (Y2773); Other external ear anomaly with hearing impairment (P402.), codes under Disorder of hearing (Xa7SW); Other external ear anomaly with hearing impairment NOS (P402z)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 36 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

03 Manual Dexterity Unable to pick up objects (Xa45d), Does not pick up objects (Xa45f), Difficulty picking up objects (Xa45g), Unable to manipulate objects (Xa2gV), Does not manipulate objects (Xa2gX), Difficulty manipulating objects (Xa2gY), Unable to manipulate objects relative to one another (Xa2gb), Does not manipulate objects relative to one another (Xa2gd), Difficulty manipulating objects relative to one another (Xa2ge), Able to bang objects together (Xa2gg), Does bang objects together (Xa2gi), Difficulty banging objects together (Xa2gk), Unable to put one object inside another (Xa2gn), Does not put one object inside another (Xa9Vx), Difficulty putting one object inside another (Xa2gp), Unable to place one object on top of another (Xa2gs), Does not place one object on top of another (Xa2gu), Difficulty placing one object on top of another (Xa2gv), Unable to pass things from hand to hand (Xa45j), Does not pass things from hand to hand (Xa45m), Difficulty passing things from hand to hand (Xa45n), Unable to turn pages (Xa45q), Does not turn pages (Xa45s), Difficulty turning pages (Xa45t), Unable to use a key (Xa45w), Does not use a key (Xa45y), Difficulty using a key (Xa45z), Unable to operate taps (Xa3Fj), Does not operate taps (Xa3Fl), Difficulty operating taps (Xa3Fm), Unable to turn taps on (Xa3Fs), Difficulty turning taps on (Xa3Fv), Unable to turn taps off (Xa3Fz), Difficulty turning taps off (Xa3G3), Unable to wring out a cloth (Xa462), Difficulty wringing out a cloth (Xa465), Unable to manage clothes fastenings (Xa4fp), Difficulty managing clothes fastenings (Xa4fs), Unable to do up clothes fastenings (Xa2xd), Difficulty doing up clothes fastenings (Xa2xg), Unable to undo clothes fastenings (Xa2xj), Difficulty undoing clothes fastenings (Xa2xm), Unable to tie shoe laces (Xa9X8), Difficulty tying shoe laces (Xa9XB), Unable to wind up watch (Xa468), Difficulty winding up watch (Xa46B), Unable to open and close containers (Xa46E), Difficulty opening and closing containers (Xa46H), Unable to put lid on container (Xa2gy), Difficulty putting lid on container (Xa2h1), Unable to screw on a lid (Xa46K), Difficulty screwing on a lid (Xa46N)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 37 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code

Unable to unscrew a lid (Xa46Q), Difficulty unscrewing a lid (Xa46T), Unable to thread a needle (Xa46W), Difficulty threading a needle (Xa46Z), Unable to cut with scissors (Xa46c), Difficulty cutting with scissors (Xa46f), Unable to use tweezers (Xa46i), Difficulty using tweezers (Xa46l), Unable to perform drawing activities (Xa46o), Difficulty performing drawing activities (Xa46r), Unable to perform writing activities (Xa46u), Difficulty performing writing activities (Xa46x), Difficulty writing (XaAzQ), Unable to perform copying activities (Xa470), Difficulty performing copying activities (Xa473)

04 Memory or ability to concentrate, learn or Learning difficulties (13Z4E), codes understand (Learning Disability) under Mental retardation (E3...); codes under Memory impairment (X75xU); codes under Reduced concentration (X760c)

05 Mobility and Gross Motor Gross motor disability (Ub0io); Impaired mobility (Ua1nC)

06 Perception of Physical Danger Unable to comprehend concept of danger (Xa8LE); Difficulty comprehending concept of danger (Xa8LF)

07 Personal, Self Care and Continence Neglect of personal hygiene (X766E); codes under Self-neglect (X766C); Personal care disability (Ub0ib); Urinary incontinence (1A23.); Double incontinence (X30C5); Incontinence of faeces (XE0rG); Incontinent (X909i)

08 Progressive Conditions and Physical Health (such H/O long term condition (XaZJC) as HIV, cancer, multiple sclerosis, fits etc.)

09 Sight Codes under Impaired vision (XE16L); Combined visual and hearing impairment (XaYPJ)

10 Speech Codes under Communication disorder (Xa0tn)

XX Other Disability NOS (13VCZ)

NN No Disability No current problems or disability (1152.)

ZZ Not Stated (Person asked but declined to provide Disability status not given - patient a response) refused (XaR8E)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 38 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M007020 Disability Impact Perception This is 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. This will be recorded using CTV3 Read codes. Recording the following CTV3 Read codes will extract the relevant National Code for both Disability Code and Disability Impact Perception.

National Code Extract Description SystmOne Read code

01 - 01 Limited a lot by behavioural and emotional disability Limited a lot by behavioural and emotional disability (Y15fa)

01 - 02 Limited a little by behavioural and emotional Limited a little by behavioural and disability emotional disability (Y15fb)

01 - 03 Not limited by behavioural and emotional disability Not limited by behavioural and emotional disability (Y15fc)

01 - 04 Declined to assess impact of behavioural and Declined to assess impact of emotional disability behavioural and emotional disability (Y15fd)

02 - 01 Limited a lot by hearing disability Limited a lot by hearing disability (Y15fe)

02 - 02 Limited a little by hearing disability Limited a little by hearing disability (Y15ff)

02 - 03 Not limited by hearing disability Not limited by hearing disability (Y160a)

02 - 04 Declined to assess impact of hearing disability Declined to assess impact of hearing disability (Y160b)

03 - 01 Limited a lot by manual dexterity disability Limited a lot by manual dexterity disability (Y160c)

03 - 02 Limited a little by manual dexterity disability Limited a little by manual dexterity disability (Y160d)

03 - 03 Not limited by manual dexterity disability Not limited by manual dexterity disability (Y160e)

03 - 04 Declined to assess impact of manual dexterity Declined to assess impact of manual disability dexterity disability (Y160f)

04 - 01 Limited a lot by learning disability Limited a lot by learning disability (Y161a)

04 - 02 Limited a little by learning disability Limited a little by learning disability (Y161b)

04 - 03 Not limited by learning disability Not limited by learning disability (Y161c)

04 - 04 Declined to assess impact of learning disability Declined to assess impact of learning disability (Y161d)

05 - 01 Limited a lot by mobility and gross motor disability Limited a lot by mobility and gross motor disability (Y161e)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 39 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code

05 - 02 Limited a little by mobility and gross motor disability Limited a little by mobility and gross motor disability (Y161f)

05 - 03 Not limited by mobility and gross motor disability Not limited by mobility and gross motor disability (Y162a)

05 - 04 Declined to assess impact of mobility and gross Declined to assess impact of mobility motor disability and gross motor disability (Y162b)

06 - 01 Limited a lot by disability of perception of physical Limited a lot by disability of perception danger of physical danger (Y162c)

06 - 02 Limited a little by disability of perception of physical Limited a little by disability of danger perception of physical danger (Y162d)

06 - 03 Not limited by disability of perception of physical Not limited by disability of perception danger of physical danger (Y162e)

06 - 04 Declined to assess impact of disability of perception Declined to assess impact of disability of physical danger of perception of physical danger (Y162f)

07 - 01 Limited a lot by disability of care and continence Limited a lot by disability of care and continence (Y163a)

07 - 02 Limited a little by disability of care and continence Limited a little by disability of care and continence (Y163b)

07 - 03 Not limited by disability of care and continence Not limited by disability of care and continence (Y163c)

07 - 04 Declined to assess impact of disability of care and Declined to assess impact of disability continence of care and continence (Y163d)

08 - 01 Limited a lot by physical ill health disability Limited a lot by physical ill health disability (Y163e)

08 - 02 Limited a little by physical ill health disability Limited a little by physical ill health disability (Y163f)

08 - 03 Not limited by physical ill health disability Not limited by physical ill health disability (Y164a)

08 - 04 Declined to assess impact of physical ill health Declined to assess impact of physical disability ill health disability (Y164b)

09 - 01 Limited a lot by sight disability Limited a lot by sight disability (Y164c)

09 - 02 Limited a little by sight disability Limited a little by sight disability (Y164d)

09 - 03 Not limited by sight disability Not limited by sight disability (Y164e)

09 - 04 Declined to assess impact of sight disability Declined to assess impact of sight disability (Y164f)

10 - 01 Limited a lot by speech disability Limited a lot by speech disability (Y165a)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 40 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Read code

10 - 02 Limited a little by speech disability Limited a little by speech disability (Y165b)

10 - 03 Not limited by speech disability Not limited by speech disability (Y165c)

10 - 04 Declined to assess impact of speech disability Declined to assess impact of speech disability (Y165d)

NN - 01 Limited a lot but no disability recorded Limited a lot but no disability recorded (Y166c)

NN - 02 Limited a little but no disability recorded Limited a little but no disability recorded (Y166d)

NN - 03 Not limited and no disability recorded Not limited and no disability recorded (Y166e)

XX - 01 Declined to assess impact of disability Declined to assess impact of disability (Y166f)

MHS008 Mental Health Care Plan Type

M008070 Care Plan Identifier This is a unique ID, which identifies each individual Care Plan within an organisation. SystmOne will extract this information automatically.

M008901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M008030 Care Plan Type (Mental Health) The type of Care Plan for the patient, recorded by the service. This is captured from the Category field on the Care Plan. SystmOne will extract national codes for this in line with the below SystmOne options.

National Code Extract Description SystmOne Configured List Option

10 Mental Health Care Plan Mental Health

11 Urgent and Emergency Mental Health Care Plan Urgent and Emergency Mental Health

12 Mental Health Crisis Plan Mental Health Crisis

13 Positive Behaviour Support Plan Positive Behaviour Support

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

M008010 Care Plan Creation Date The date that a Care Plan was created for a patient. SystmOne will automatically extract this item from the Date added field on the Care Plan.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 41 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M008080 Care Plan Creation Time The time that a Care Plan was created for a patient. SystmOne will automatically extract the information for this field.

M008020 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. SystmOne will automatically extract this from the date the Care Plan was last amended.

M008090 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. SystmOne will automatically extract this from the time the Care Plan was last amended.

MHS010 Assistive Technology To Support Disability Type TPP have agreed with NHS Digital that we will not be supporting this field until NHS Digital are able to supply a list of SNOMED or CTV3 codes that should be extracted as an Assistive Technology Finding.

MHS011 Social and Personal Circumstances

M011901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M011020 Social and Personal Circumstance (SNOMED CT) The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person. These are recorded as part of registration, or on the Patient Details dialog which can be found by going to Patient>Patient Maintenance>Patient Details. These are recorded using CTV3 codes and mapped to SNOMED CT. The circumstances that are collected are:

Religious or Other Belief System Affiliation Group Code

SystmOne Read code Code description

135.. & Child Religious Affiliation

XaLUd Patient religion unknown

XaE4G Religion not given - patient refused

135D. Not religious

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 42 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

Person Stated Sexual Orientation Code

SystmOne Read code Code description

X766q Heterosexual

E220. & Child Homosexual

X766r Bisexual

Y178b NDTMS - Other sexual orientation

XaPO2 Sexual orientation unknown

XaWSA Sexual orientation not given – patient refused

M011010 Social and Personal Circumstance Recorded Date The date that the Social and Personal Circumstance was recorded.

MHS012 Overseas Visitor Charging Category

M012901 Local Patient Identifier This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M012010 Overseas Visitor Charging Category The charging category relating to an Overseas Visitor Status. This can be recorded using the quick action “Overseas Charging Category” with the following options available to select.

National Code Extract Description Overseas Charging Category Configured List option

A Standard NHS–funded PATIENT Charging category A: Standard NHS - funded PATIENT

B Immigration Health Surcharge payee Charging category B: Immigration Health Surcharge payee

C Charge-exempt Overseas Visitor (European Charging category C: Charge-exempt Economic Area) Overseas Visitor (European Economic Area)

D Chargeable European Economic Area PATIENT Charging category D: Chargeable European Economic Area PATIENT

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

F Chargeable non-European Economic Area Charging category F: Chargeable non- PATIENT European Economic Area PATIENT

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 43 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Overseas Charging Category Configured List option

P Decision Pending Charging category P: Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY

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

M012020 Overseas Visitor Charging Category Applicable Date This is the date the Overseas Charging Category was recorded. SystmOne will extract this information automatically.

MHS101 Service or Team Referral

M101902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M101901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M101922 Organisation Identifier (Code of Commissioner) This is the ID of the organisation responsible for the GP Practice where the patient is registered at the time of the referral to the Service or Team, e.g. the Clinical Commissioning Group (CCG). In SystmOne this is the CCG code for the patient’s registered GP at the point of the patient’s referral. Where there is no registered GP Practice, SystmOne will generate a CCG code based on the patient’s address. Where there is no fixed address for the patient, SystmOne will use the Commissioning CCG ID of the team recorded for that referral. Where there is no Commissioning CCG ID for the team on the referral, the ID of the organisation responsible for the Mental Health Trust will be used.

M101010 Referral Request Received Date This is the date the referral request was received by the Health Care Provider. SystmOne will automatically extract this item from the Date referral received field on the Record Incoming Referral dialog.

M101020 Referral Request Received Time This is the time the referral request was received by the Health Care Provider. SystmOne will automatically extract this item from the Time referral received field on the Record Incoming Referral dialog.

M101907 NHS Service Agreement Line Number This can be recorded on the Service Agreements screen (Setup>Users & Policy>Service Agreement) by right clicking on the relevant CCG and selecting Add Specific Service Line Agreement.

M101030 Source of Referral for Mental Health A classification which identifies the source of referral to a Mental Health Service. This should be recorded on the Referral Source field on the Record Referral In dialog. SystmOne will extract national codes for this in line with the below SystmOne options.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 44 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Referral Source Configured List option

Primary Health Care

A1 General Medical Practitioner General Medical Practitioner, GP (National code: 3)

A2 Health Visitor Health Visitor, Health Visitor / School Nurse

A3 Other Primary Health Care Other Primary Health Care

A4 Maternity Service Maternity Service

Self Referral

B1 Self Self, Self (YP Services), Self – Referral, Self referral, Self-Referral, Self-Referral (National code: 06)

B2 Carer Carer, Carer/Relative

Local Authority Services

C1 Social Services Social Services

C2 Education Service Education Services, Education Service

C3 Housing Service Housing Service

Employer

D1 Employer Employer, Employer (YP Services)

D2 Occupational Health Occupational Health

Justice System

E1 Police Police

E2 Courts Courts

E3 Probation Service Probation Service

E4 Prison Prison Service

E5 Court Liaison and Diversion Service Court Liaison and Diversion Service

E6 Youth Offending Team Youth Offending Team

Child Health

F1 School Nurse School Nurse

F2 Hospital-based Paediatrics Hospital-based Paediatrics

F3 Community –based Paediatrics Community-based Paediatrics, Community paediatrician

Independent/Voluntary Sector

G1 Independent sector – Medium Secure Inpatients Independent sector – Medium Secure Inpatients

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 45 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Referral Source Configured List option

G2 Independent Sector – Low Secure Inpatient Independent Sector – Low Secure Inpatient

G3 Other Independent Sector Mental Health Services Other Independent Sector Mental Health Services

G4 Voluntary Sector Voluntary Sector

Acute Secondary Care

H1 Accident and Emergency Department A&E Department, Accident And Emergency Department

H2 Other secondary care specialty Other Secondary Care Specialty

Other Mental Health NHS Trust

I1 Temporary transfer from another Mental Health Temporary transfer from another Mental NHS Trust Health NHS Trust

I2 Permanent transfer from another Mental Health Permanent Transfer from MH NHS Trust

Internal referrals from Community Mental Health Team (within own NHS Trust)

J1 Community Mental Health Team (Adult Mental Community Mental Health Team (Adult Health) Mental Health) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

J2 Community Mental Health Team (Older people) Community Mental Health Team (Older people) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

J3 Community Mental Health Team (Learning Community Mental Health Team Disabilities) (Learning Disabilities) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 46 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Referral Source Configured List option

J4 Community Mental Health Team (Child and Community Mental Health Team (Child Adolescent Mental Health) and Adolescent Mental Health) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

Internal referrals from Inpatient Service (within own NHS Trust)

K1 Inpatient Service (Adult Mental Health) Inpatient Service (Adult Mental Health) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

K2 Inpatient Service (Older People) Inpatient Service (Older People) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

K3 Inpatient Service (Forensics) Inpatient Service (Forensics) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

K4 Inpatient Service (Child and Adolescent Mental Inpatient Service (Child and Adolescent Health) Mental Health) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

K5 Inpatient Service (Learning Disabilities) Inpatient Service (Learning Disabilities) However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

Transfer by graduation (within own NHS Trust)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 47 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Referral Source Configured List option

L1 Transfer by graduation from Child and Adolescent Transfer by graduation from Child and Mental Health Services to Adult Mental Health Adolescent Mental Health Services to Services Adult Mental Health Services However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

L2 Transfer by graduation from Adult Mental Health Transfer by graduation from Adult Services to Older Peoples Mental Health Services Mental Health Services to Older Peoples Mental Health Services However, P1: Internal Referral will be extracted in the MHSDS as outlined in Mental Health Services Data Set (MHSDS) v2.0.2 User Guidance published by NHS Digital

Other

M1 Asylum Services Asylum Services

M2 Telephone or Electronic Access Service Telephone or Electronic Access Service, NHS Direct Team

M3 Out of Area Agency Out of Area Agency

M4 Drug Action Team / Drug Misuse Agency Drug Action Team / Drug Misuse Agency

M5 Jobcentre Plus Job Centre Plus, YP Job Centre Plus

M6 Other service or agency Other Agency

M7 Single Point of Access Service Single Point of Access

Improving Access to Psychological therapies

N3 Improving Access to Psychological therapies Improving Access to Psychological Service therapies Service

Internal

P1 Internal Referral Inpatient Service (Adult Mental Health), Inpatient Service (Older People), Inpatient Service (Forensics), Inpatient Service (Child and Adolescent Mental Health), Inpatient Service (Learning Disabilities)

M101180 Organisation Identifier (Referring) This is the Organisation Identifier of the referring organisation. In SystmOne the referring organisation is recorded in the Referrer field when recording a new referral. For Mental Health organisations SystmOne will automatically extract the overarching Trust code.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 48 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M101050 Referring Care Professional Staff Group (Mental Health and Community Care) This is the staff group of the care professional who referred the patient to a Mental Health Service. SystmOne will automatically extract this information based on the employment role of the staff member recorded on the Referrer field on the Referral In dialog.

National Code Extract Description Employment Role

Allied Health Professionals

A01 Art Therapist Art Therapist

A02 Clinical Psychologist Clinical Psychologist

A03 Dietitian Dietitian

A04 Drama Therapist Drama Therapist

A05 Music Therapist Music Therapist

A06 Occupational Therapist Occupational Therapist

A07 Orthotist Orthotist

A08 Physiotherapist Physiotherapist

A09 Podiatrist Chiropodist/Podiatrist; Podiatrist

A10 Prosthetist Prosthetist

A11 Psychotherapist Psychotherapist

A12 Radiographer Radiographer

A13 Speech & Language Therapist Speech & Language Therapist

A14 Orthoptist Orthoptist

Medical/Dental

M02 Consultant Consultant

M03 General Medical Practitioner General Medical Practitioner

Nursing, Health Visitors and Midwifery

N01 Midwife Midwife

N02 District Nurse Community Nurse; District Nurse

N03 Health Visitor Health Visitor

N04 Macmillan Nurse Macmillan Nurse

N05 School Nurse School Nurse

N06 Specialist Nursing - Active Case Management Specialist Nurse Practitioner (Community Matrons)

N31 Practice Nursing Practice Nurse

N32 Staff Nurse Staff Nurse; Nurse Access Role

Other Care Professionals

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 49 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description Employment Role

C01 Appliances Technician Technician

C02 Audiologist Audiologist

C03 Counsellor Counsellor

C04 Nursery Nurse Nursery Nurse

C06 Play Therapist Play Therapist

C07 Social Worker Social Worker

C12 Healthcare Assistant Healthcare Assistant

C13 Health Care Support Worker Health Care Support Worker

C99 Other Care Professional 'Other' Community Health Service; Other Community Health Service; Other Health Care Professionals

M101070 Clinical Response Priority Type This is the priority of a request for services. This can be recorded via the Priority field on the Referral In dialog.

National Code Extract Description Priority

1 Emergency Emergency

2 Urgent/serious High/Urgent

3 Routine Routine

M101080 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. This can be recorded via the Referral In Reason field on the Referral In dialog. This field is only displayed if a preference has been set. This can be enabled by going to Organisation Preferences>Secondary Care>Miscellaneous>Record Extra Referral Details

National Code Extract Description SystmOne Configured List Option

01 (Suspected) First Episode Psychosis (Suspected) First Episode Psychosis

02 Ongoing or Recurrent Psychosis Ongoing or Recurrent Psychosis

03 Bipolar disorder Bipolar Disorder

04 Depression Depression

05 Anxiety Anxiety

06 Obsessive compulsive disorder Obsessive Compulsive Disorder

07 Phobias Phobia

08 Organic brain disorder Organic brain disorder

09 Drug and alcohol difficulties Drug and alcohol difficulties

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 50 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

10 Unexplained physical symptoms Unexplained physical symptoms

11 Post-traumatic stress disorder Post Traumatic Stress Disorder

12 Eating disorders Eating Disorders

13 Perinatal mental health issues Perinatal mental health issues

14 Personality disorders Personality disorders

15 Self harm behaviours Self harm behaviours

16 Conduct disorders Conduct disorders

18 In crisis In crisis

19 Relationship difficulties Relationship Issues

20 Gender Discomfort issues Gender Discomfort issues

21 Attachment difficulties Attachment difficulties

22 Self – care issues Self - care issues

23 Adjustment to health issues Adjustment to health issues

24 Neurodevelopmental Conditions, excluding Neurodevelopmental Conditions, Autism Spectrum Disorder excluding Autism Spectrum Disorder

25 Suspected Autism Spectrum Disorder Suspected Autism Spectrum Disorder

26 Diagnosed Autism Spectrum Disorder Diagnosed Autism Spectrum Disorder

27 Preconception perinatal mental health concern Preconception perinatal mental health concern

M101140 Reason For Out Of Area Referral (Adult Acute Mental Health) The reason why a service has received a referral request, for a person: -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. This is recorded in the Reason for out of area referral field of the Referral In dialog.

National Code Extract Description SystmOne Configured List Option

10 Unavailability of bed at referring Unavailability of bed at referring organisation organisation

11 Safeguarding Safeguarding

12 Offending restrictions Offending restrictions

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

14 Patient choice Patient choice

15 Patient away from home Patient away from home

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 51 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

99 Not Known (Not Recorded) Not Known (Not Recorded)

M101120 Discharge Plan Creation Date The date that a Discharge Plan was created for a patient. SystmOne will automatically extract this from the Date Added field on a Care Plan, where the Care Plan Category has been flagged as a Discharge Plan.

M101913 Discharge Plan Creation Time The time that a Discharge Plan was created for a patient. SystmOne will automatically extract the information for this field.

M101130 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. SystmOne will automatically extract this from the date the Care Plan was last amended, where the Care Plan Category has been flagged as a Discharge Plan.

M101200 Discharge Plan Last Updated Time The time 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 Time. SystmOne will automatically extract this from the time the Care Plan was last amended, where the Care Plan Category has been flagged as a Discharge Plan.

M101090 Service Discharge Date Service Discharge Date is the date a patient was discharged from a service. For this field, SystmOne will automatically extract the date the referral is ended. This can be recorded by right clicking on a referral and selecting End Referral.

M101110 Service Discharge Time Service Discharge Time is the time a patient was discharged from a service. For this field, SystmOne will automatically extract the time the referral is ended. This can be recorded by right clicking on a referral and selecting End Referral.

M101100 Discharge Letter Issues Date (Mental Health and Community Care) This is the date a discharge letter has been issued. The discharge letter will need to be linked to the relevant referral in order to be extracted. This can be done by going to the New Journal, right-clicking on the consultation containing the discharge letter and selecting Link to Referral. SystmOne will extract the date of the consultation the discharge letter was created in.

MHS102 Service or Team Type Referred To

M102905 Care Professional Team Local Identifier Care Professional Team Local Identifier is a unique local ‘team’ ID within a Health Care Provider and will be assigned automatically by SystmOne.

M102902 Service Request Identifier The unique identifier for a service request. SystmOne will automatically extract this item.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 52 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M102010 Service or Team Type referred to (Mental Health) This is the type of team that the patient has been referred to. For this field SystmOne will extract the type of team set against the team the patient is referred to on the Referral In dialog. The team type is set by going to Setup > Users & Policy > Configure Teams.

National Code Extract Description SystmOne Configured List Option

General Mental Health Services

A01 Day Care Service Day Care Service

A02 Crisis Resolution Team/Home Treatment Crisis Resolution Team/Home Treatment Service Service

A03 Crisis Resolution Team Crisis Resolution Team

A04 Home Treatment Service Home Treatment Service

A05 Primary Care Mental Health Service Primary Care Mental Health Service

A06 Community Mental Health Team – Functional Community Mental Health Team – Functional

A07 Community Mental Health Team – Organic Community Mental Health Team – Organic

A08 Assertive Outreach Team Assertive Outreach Team

A09 Rehabilitation & Recovery Service Rehabilitation & Recovery Service

A10 General Psychiatric Service General Psychiatric Service

A11 Psychiatric Liaison Service Psychiatric Liaison Service

A12 Psychotherapy Service Psychotherapy Service

A13 Psychological Therapy Service (non IAPT) Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis Early Intervention Team for Psychosis

A15 Young Onset Dementia Team Young Onset Dementia Team

A16 Personality Disorder Service Personality Disorder Service

A17 Memory Services/Clinic Memory Services/Clinic

A18 Single Point of Access Service Single Point of Access Service

A19 24/7 Crisis Response Line 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service Health Based Place Of Safety Service

Forensic Services

B01 Forensic Mental Health Service Forensic Mental Health Service

B02 Forensic Learning Disability Service Forensic Learning Disability Service

Specialist Mental Health Services

C01 Autistic Spectrum Disorder Service Autistic Spectrum Disorder Service

C02 Peri-Natal Mental Illness Service Peri-Natal Mental Illness Service

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 53 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

C03 Eating Disorders/Dietetics Service Eating Disorders/Dietetics Service

C04 Neurodevelopment Team Neurodevelopment Team

C05 Paediatric Liaison Service Paediatric Liaison Service

C06 Looked After Children Service Looked After Children Service

C07 Community Young Offenders Service Community Young Offenders Service

C08 Acquired Brain Injury Service Acquired Brain Injury Service

C09 Community Eating-Disorder Service for Children Community Eating-Disorder Service for and Young People Children and Young People

Other Mental Health Services

D01 Substance Misuse Team Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service Prison Psychiatric Inreach Service

D04 Asylum Service Asylum Service

D05 Individual Placement and Support Service Individual Placement and Support Service

Learning Disability Services

E01 Community Team for Learning Disabilities Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service Epilepsy/Neurological Service

E03 Specialist Parenting Service Specialist Parenting Service

E04 Enhanced/Intensive Support Service Enhanced/Intensive Support Service

Other

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

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

M102020 Child and Adolescent Mental Health Tier or Service This is the tier of service the CAMHS team operates at. This is set again the team and can be configured by going to Setup > Users & Policy > Configure Teams and selecting an appropriate tier on the New Team or Amend Team dialogs.

M102040 Referral Closure Date This is the date that the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. SystmOne will extract the date a referral was ended via the End Referral dialog, accessed from the Referrals node of the patient record.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 54 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M102080 Referral Closure Time This is the time that the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. SystmOne will extract the time a referral was ended via the End Referral dialog, accessed from the Referrals node of the patient record.

M102050 Referral Rejection Date This is the date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. For this item, SystmOne will extract the date from the Date of decision field when the outcome of a referral is set as Declined in the Outcome of Referral field of the Referral In dialog.

M102090 Referral Rejection Time This is the time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. For this item, SystmOne will extract the time from the Date of decision field when the outcome of a referral is set as Declined in the Outcome of Referral field of the Referral In dialog.

M102060 Referral Closure Reason This is the reason that a referral has been closed. A Referral Request can be closed as a result of a patient being discharged from the service. This is the reason selected in the End Reason field on the Select Referral End Reason when a user right clicks and selects to End Referral on a Referral In. Below are the configured list options SystmOne will extract as per the MHSDS specification.

National Code Extract Description SystmOne Configured List Option

01 Admitted elsewhere (at the same or other Discharged – admitted elsewhere Health Care Provider)

02 Treatment completed Discharged – Treatment completed

03 Moved out of the area Moved out of area

04 Not further treatment appropriate Discharged – No further treatment appropriate

05 Patient did not attend Patient failed to attend (DNA’d)

06 Patient died Died

07 Patient requested discharge Discharged – Patient requested discharged

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

09 Refused to be seen Discharged – Refused to be seen

M102070 Referral Rejection Reason This is the reason that a Referral Request has been rejected by the service. SystmOne will automatically extract this as national code 02 for any referrals that have an outcome set as declined.

National Code Extract Description Rejection Reason

02 Inappropriate referral request (Referral request Automatically extracted for any referral is inappropriate for the services offered by the where the outcome has been set as Health Care Provider) declined

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 55 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS103 Other Reason for Referral

M103902 Service Request Identifier The unique identifier for a service request. SystmOne will automatically extract this item.

M103010 Other Reason for Referral (Mental Health) This is recorded as the secondary reason for referral in the Extra Details section of the Referral In dialog. The extra details section must be enabled in order to do this. The preference to enable this is Organisation Preferences>Secondary Care>Miscellaneous>Record Extra Referral Details.

National Code Extract Description SystmOne Configured List Options

01 (Suspected) First Episode Psychosis (Suspected) First Episode Psychosis

02 Ongoing or Recurrent Psychosis Ongoing or Recurrent Psychosis

03 Bipolar disorder Bipolar Disorder

04 Depression Depression

05 Anxiety Anxiety

06 Obsessive compulsive disorder Obsessive Compulsive Disorder

07 Phobias Phobia

08 Organic brain disorder Organic brain disorder

09 Drug and alcohol difficulties Drug and alcohol difficulties

10 Unexplained physical symptoms Unexplained physical symptoms

11 Post-traumatic stress disorder Post Traumatic Stress Disorder

12 Eating disorders Eating Disorders

13 Perinatal mental health issues Perinatal mental health issues

14 Personality disorders Personality disorders

15 Self harm behaviours Self harm behaviours

16 Conduct disorders Conduct disorders

18 In crisis In crisis

19 Relationship difficulties Relationship Issues

20 Gender Discomfort issues Gender Discomfort issues

21 Attachment difficulties Attachment difficulties

22 Self – care issues Self - care issues

23 Adjustment to health issues Adjustment to health issues

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 56 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Options

24 Neurodevelopmental Conditions, excluding Neurodevelopmental Conditions, Autism Spectrum Disorder excluding Autism Spectrum Disorder

25 Suspected Autism Spectrum Disorder Suspected Autism Spectrum Disorder

26 Diagnosed Autism Spectrum Disorder Diagnosed Autism Spectrum Disorder

27 Preconception perinatal mental health concern Preconception perinatal mental health concern

MHS104 Referral to Treatment

M104902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M104020 Patient Pathway Identifier This is an identifier which uniquely identifies a patient pathway. This is recorded on the Pathway ID field on the Referral In dialog when creating a Referral In and choosing to record an RTT period. If the patient pathway began using the NHS e-Referral service (e-RS), the patient pathway will instead be uniquely identified by the UBRN of the first referral and the organisation code of NHS Connecting for Health (X09).

M104080 Organisation Identifier (Patient Pathway Identifier Issuer) This is the organisation identifier of the organisation issuing the Patient Pathway identifier. This can be recorded in the Pathway ID Issuer field on the Record Referral In dialog.

M104040 Waiting Time Measurement Type This is the type of waiting time measurement which may be applied during a Patient Pathway. This is recorded in the Led by field on the Record Referral In dialog. National Code Extract Description SystmOne Description

02 Allied Health Professional Referral To Allied health professional Treatment Measurement

09 Other Referral To Treatment Measurement Consultant; Other Type

M104050 Referral to Treatment Period Start Date The start date of a Referral to Treatment period. This is the Wait Start recorded on the Record Referral In dialog.

M104060 Referral to Treatment Period End Date The end date of a Referral to Treatment period. This is the Event date of an RTT Status that stops the clock, as recorded on the patient’s record. This can be recorded on the RTT Status History dialog by right clicking on a Referral on the Referrals node.

M104070 Referral to Treatment Period Status The status of an activity for the Referral to Treatment period decided by the Lead Care Professional. This is the RTT status recorded at the point that the consultation started. RTT status can be recorded on the Referral In and

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 57 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

RTT Status History dialog (this can be accessed by right-clicking on the Referral in the Referrals Node and selecting Record RTT Status).

National Code Extract Description SystmOne Description

The first activity in a Referral to Treatment period where the first definitive treatment will be a subsequent activity

10 First activity - first activity in a referral to First activity treatment period

11 Active monitoring end - first activity at the Active monitoring end start of a new referral to treatment period following active monitoring

12 Consultant or NHS allied health Referral from consultant professional service (referral to treatment measurement) referral - the first activity at the start of a new referral to treatment period following a decision to refer directly to the consultant or NHS allied health professional service (referral to treatment measurement) for a separate condition

Subsequent activity during a referral to treatment period

20 Subsequent activity during a referral to Subsequent activity treatment period - further activities anticipated

21 Transfer to another health care provider - Transfer to another provider subsequent activity by another health care provider during a referral to treatment period anticipated

Activity that ends the referral to treatment period

30 Start of first definitive treatment. First definitive treatment

31 Start of active monitoring initiated by the Patient led active monitoring patient

32 Start of active monitoring initiated by the Clinician led active monitoring care professional

33 Did not attend - the patient did not attend Patient DNA first contact activity the first care activity after the referral

34 Decision not to treat - decision not to treat Decision not to treat made or no further contact required

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 58 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Description

35 Patient declined offered treatment Patient refused treatment

36 Patient died before treatment Patient died

Activity that is not part of a referral to treatment period

90 After treatment - first definitive treatment Activity after RTT period occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment)

91 Active monitoring - care activity during Active monitoring activity active monitoring

92 Not yet referred - not yet referred for Patient is not referred treatment, undergoing diagnostic tests by general practitioner before referral

98 Not applicable - activity not applicable to Not applicable to RTT referral to treatment periods

Activity where the referral to treatment period status is not yet known

99 Not yet known RTT not yet known

MHS105 Onward Referral For the purpose of the MHSDS, an Onward Referral is a Referral Out that has been created in a consultation that is linked to a Referral In.

M105902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M105010 Onward Referral Date The date the patient was referred to another service, which may be in the same or a different organisation. This is the date of the Referral Out.

M105060 Onward Referral Time The time the patient was referred to another service, which may be in the same or a different organisation. This is the time of the Referral Out.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 59 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M105020 Onward Referral Reason This is the reason why the patient was referred to another service. This can be recorded on the Reason for Referral field when recording a Referral Out.

National Code Extract Description SystmOne Configured List Option

01 Transfer of Clinical Responsibility Transfer of Clinical Responsibility

02 For Opinion Only For Opinion Only

03 For Diagnostic Only For Diagnostic Only

04 New Referral (Non Transfer) New Referral (Non Transfer)

96 Other Other reason for onward referral

98 Not Applicable Onward referral reason not applicable

99 Not Known Onward referral reason not known

M105050 Reason For Out Of Area Referral (Adult Acute Mental Health) The reason that a person 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 person's Mental Health Care Coordinator cannot visit the person as often as stated in the Organisation's policy. This is recorded in the Reason for out of area referral field of the Referral Out dialog.

National Code Extract Description SystmOne Configured List Option

10 Unavailability of bed at referring Unavailability of bed at referring organisation organisation

11 Safeguarding Safeguarding

12 Offending restrictions Offending restrictions

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

14 Patient choice Patient choice

99 Not Known (Not Recorded) Not Known (Not Recorded)

M105090 Organisation Identifier (Receiving) This is the organisation identifier of the organisation that is receiving the onward referral. SystmOne will automatically extract this information based on the Recipient ID of the organisation receiving the Referral Out, as recorded on the Referral Out dialog. If the organisation ID is set up against the organisation selected in the Address Book this will automatically populate. The ID can be amended both on the Referral Out dialog and from within the Address Book by right-clicking on the organisation and selecting Amend.

MHS107 Medication Prescription This table is not yet included in TPP’s MHSDS extract. This table was included in NHS Digital documentation for piloting purposes only to support future implementation. These data items have not yet been approved or mandated by NHS Digital.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 60 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS201 Care Contact

M201903 Care Contact Identifier The care contact identifier is used to uniquely identify the care contact within the health care provider. SystmOne will automatically generate this item.

M201902 Service Request Identifier This is the unique identifier for a service request. SystmOne will automatically generate this upon recording a new referral.

M201905 Care Professional Team Local Identifier Care Professional Team Local Identifier is a unique local team ID within a Health Care Provider. SystmOne will automatically generate this based on the team selected in the Team field on the Referral In dialog.

M201010 Care Contact Date The date on which a Care Contact took place or, if cancelled, was scheduled to take place. SystmOne defines a care contact as a Visit or Appointment and will automatically extract the date of any Appointment or Visit recorded on the system for this field.

M201020 Care Contact Time The time at which a Care Contact took place or, if cancelled, was scheduled to take place. SystmOne defines a care contact as a Visit or Appointment and will automatically extract the time of any Appointment or Visit recorded on the system for this field.

M201922 Organisation Identifier (Code of Commissioner) This is the ID of the organisation responsible for the GP Practice where the patient is registered at the time of the referral to the Service or Team, e.g. the Clinical Commissioning Group (CCG). In SystmOne this is the CCG code for the patient’s registered GP at the point of the patient’s referral. Where there is no registered GP Practice, SystmOne will generate a CCG code based on the patient’s address. Where there is no fixed address for the patient, SystmOne will use the Commissioning CCG ID of the team recorded for that referral. Where there is no Commissioning CCG ID for the team on the referral, the ID of the organisation responsible for the Mental Health Trust will be used.

M201030 Administrative Category Code This is the administrative category of the patient. This is captured when recording the Outcome of an Appointment or Visit on the Outcome of Contact dialog, once the contact has been saved.

National Code Extract Description SystmOne Description

01 NHS patient, including Overseas Visitors NHS Patient charged under the National Health Service

(Overseas Visitors Hospital Charging Regulations)

02 Private patient, one who uses Private Patient accommodation or services authorised

under the National Health Service Act 2006

04 Category II patient, one for whom work is Category II Patient 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.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 61 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M201040 Clinical Contact Duration of Care Contact This is the duration of the Appointment or Visit. Appointment durations are recorded in the Duration field of the Book New Appointment dialog. Visit durations are recorded in the Duration field of the Record Visit Request dialog. Telephone consultations should be recorded as Appointments in order to capture this information.

M201050 Consultation Type This indicates the type of consultation for a service. This can be either an initial or a follow-up consultation. SystmOne will automatically extract this information based on whether or not the Visit or Appointment is the first visit or appointment recorded against a Referral.

National Code Extract Description SystmOne Description

01 Initial Consultation First visit or appointment against a referral

02 Follow-up Consultation Any following visits or appointments against a referral

M201060 Care Contact Subject This is the person that the Appointment or Visit was with. This is extracted from the Contact With field when recording a new Activity on the Event Details dialog.

National Code Extract Description SystmOne Configured List option

01 Patient Patient

02 Patient Proxy (in lieu of contact with a Carer; Parent; Relative; Patient Proxy patient)

M201070 Consultation Medium Used This is the communication mechanism used to relay information between the care professional and the person who is the subject of the consultation, during a care activity. This can be specified by selecting the relevant option on the Contact Method field on the Event Details dialog.

National Code Extract Description SystmOne Configured List Option

01 Face to face communication Face to face; Care delivered as Group Therapy (Face to Face)

02 Telephone Telephone; Telephone Consultation; Telephone call from a patient; Telephone call to a patient; Telephone contact to inform of results

03 Telemedicine web camera Telemedicine web camera; Telemedicine

04 Talk type for a person unable to speak Talk Type

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 62 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

05 Email Email; E-mail

06 Short Message Service (SMS) - Text Messaging SMS; Text; Short Message Service (SMS) - Text Messaging

98 Other Other

M201909 Activity Location Type Code The type of physical location where patients are seen, where services are provided, or from which requests for services are sent. This can be recorded on the Event Details in the Other Location field.

National Code Extract Description SystmOne Configured List Option

Patient main residence or related location

A01 Patient's Home Patient's Home; Home of Patient; Home

A02 Carer's Home Carer’s Home

A03 Patient's Workplace Patient's workplace

A04 Other Patient Related Location Other patient related location

Health Centre premises

B01 Primary Care Health Centre Primary Care Centre; Health Centre

B02 Polyclinic Polyclinic

General Practitioner and Ophthalmic Medical Practitioner Premises

C01 General Medical Practitioner Practice General Medical Practice; GP Surgery; GP; Surgery

C02 Dental Practice General Dental Practice

C03 Ophthalmic Medical Practitioner premises Ophthalmic Medical Practitioner premises

Walk In Centres, Out of Hours Premises and Emergency Community Dental Services

D01 Walk In Centre Walk in centre

D02 Out of Hours Centre Out of Hours Centre

D03 Emergency Community Dental Service Emergency Community Dental Service

Locations on Hospital Premises

E01 Out-Patient Clinic Out-Patient Clinic; Hospital Outpatient

E02 Ward Ward; Hospital Inpatient

E03 Day Hospital Day Hospital

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 63 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

E04 Accident and Emergency or Minor Injuries Minor Injuries Unit; A&E; A & E Department

E99 Other departments Other departments

Hospice premises

F01 Hospice Hospice; Hospice-Adult; Hospice- Children's

Nursing and Residential Homes

G01 Care Home Without Nursing Care Home Without Nursing; Residential Care Home; Residential Home

G02 Care Home With Nursing Care Home With Nursing; Nursing Home

G03 Children’s Home Children's Home

G04 Integrated Care Home Without Nursing and Care Integrated Care Home without Nursing Home With Nursing and Care Home with Nursing

Day Centre premises

H01 Day Centre Day Centre

Resource Centre premises

J01 Resource Centre Resource Centre

Dedicated Facilities for Children and Families

K01 Sure Start Children’s Centre Sure Start Children's Centre

K02 Child Development Centre Child Development Centre

Educational, Childcare and Training Establishments

L01 School School; Mainstream Schools; Special Schools

L02 Further Education College Further Education College

L03 University University

L04 Nursery Premises Nursery Premises; Nurseries/Playgroup; Nursery; Playgroup / Nursery; Playgroup/Nursery

L05 Other Childcare Premises Other Childcare Premises

L06 Training Establishments Training establishments

L99 Other Educational Premises Other educational premises

Justice and Home Office premises

M01 Prison Prison

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 64 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

M02 Probation Service Premises Probation Service premises

M03 Police Station / Police Custody Suite Police Station; Police Custody Suite

M04 Young Offenders Institute Young Offenders Institute; Young Offenders Institution

M05 Immigration Removal Centre Immigration Centre

M06 Young Offender Institution (15-17) Young Offender Institution (15-17)

M07 Young Offender Institution (18-21) Young Offender Institution (18-21)

Public locations

N01 Street or other public open space Street or other public open space

N02 Other publicly accessible area or building Other publicly accessible area or building

N03 Voluntary or charitable agency premises Voluntary or charitable agency premises; Voluntary Organisation

N04 Dispensing Optician premises Dispensing Optician premises

N05 Dispensing Pharmacy premises Dispensing Pharmacy premises

Other Locations

X01 Other locations not elsewhere classified Other locations not elsewhere classified; Other

M201160 Place of Safety Indicator An indication of whether a location is being used as a place of safety. SystmOne will automatically extract this based on the presence of Care contact at Place of Safety (Y183e) in the Care Contact.

National Code Extract Description SystmOne Read code

Y Yes – is a Place of Safety Care contact at Place of Safety (Y183e)

N No – is not a Place of Safety Absence of ‘Care contact at Place of Safety’ (Y183e) in a Care Contact

M201921 Organisation Site Identifier (Of Treatment) This is the organisation site identifier for the organisation site where the patient was treated. This will be extracted using the unit’s ODS code. The unit’s ODS code is recorded in the ODS Code field of the Community National Data Extracts Organisation Preference (Setup>Users & Policy>Organisation Preferences>Clinical Policy>Community National Data Extracts).

M201080 Group Therapy Indicator An indicator of whether a Care Activity was delivered as Group Therapy. This can be recorded by selecting the relevant option Contact Method field on the Event Details dialog.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 65 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

Y Care Activity delivered as Group Therapy Care delivered as Group Therapy (Face to Face)

N Care Activity delivered individually Absence of ‘Care delivered as Group Therapy (Face to Face)’ in a Care Contact

M201090 Attended or Did Not Attend Code This indicates whether an appointment/visit for a care contact took place, or if the appointment did not take place whether advanced warning was given. The system will extract this based on the time the patient is recorded as arrived and the appointment/visit status as outlined below. The status is recorded by right clicking on the Appointment or Visits and selecting one of the following options:

National Code Extract Description SystmOne Option SystmOne Option (Appointment) (Visits)

5 Attended on time or, if late, before Attended Finished the relevant care professional was ready to see the patient

6 Arrived late, after the relevant care If a patient is marked as N/A professional was ready to see the arrived after the appointment patient, but was seen start time and the appointment was recorded as ‘in progress’ or ‘finished’ then SystmOne will consider that the patient arrived late and could be seen

7 Patient arrived late and could not If a patient is marked as N/A be seen arrived after the appointment start time and the appointment was never marked as being in progress or finished SystmOne will consider that the patient arrived late and could not be seen

2 Appointment cancelled by, or on Cancelled by Patient Cancelled by Patient behalf of, the patient

3 Did not attend - no advance Did Not Attend No Access (DNA) warning given

4 Appointment cancelled or ‘Cancelled by Unit’ or ‘Cancelled by Unit’ or postponed by the Health Care ‘Cancelled by Other Service’ ‘Deferred’ Provider

M201100 Earliest Reasonable Offer Date This is the date of the earliest of the Reasonable Offers made to a patient for an appointment or an elective admission. The date of the Refused Offer will be extracted. If there is no recorded Refused Offer, then the date of the next booked appointment will be extracted.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 66 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

An option to record a Refused Offer will be available by right-clicking on a referral on the Referrals node, and selecting Show Refused Offers. The Patient Record must have been saved since adding the referral to the Patient Record before Show Refused Offers is available. A Refused Offer can be added from the Waiting Lists screen by selecting Show Refused Offers and then Add on the Refused Offers dialog. RTT functionality must be enabled for this data item to be recorded.

M201110 Earliest Clinically Appropriate Date This is the earliest date that it was clinically appropriate for an activity to take place. This can be recorded on the Earliest Clinically Appropriate Date field on the Record Referral In dialog. Alternatively, users can right click on a referral, select Record Earliest Clinically Appropriate Date, and record the information here. RTT functionality must be enabled for this data item to be recorded.

M201120 Care Contact Cancellation Date The date that a Care Contact was cancelled by the Provider or Patient. SystmOne will automatically extract the date an Appointment or Visit is marked as cancelled.

M201130 Care Contact Cancellation Reason The reason that a Care Contact was cancelled. On SystmOne this can be recorded on the Cancellation Reason field on the Outcome of Contact dialog, which will appear when an appointment that is linked to a referral is marked as cancelled.

National Code Extract Description SystmOne Configured List Option

001 Cancelled for Clinical Reasons Cancelled for Clinical Reasons

002 Cancelled for Non-clinical Reasons Cancelled for Non-clinical Reasons

M201140 Replacement Appointment Date Offered The Replacement Appointment/Visit Date Offered by the Health Care Provider to the patient following the cancellation of an Appointment/Visit by the Service. On SystmOne the Replacement Appointment Date Offered is defined as the next Appointment/Visit booked date after an Appointment/Visit that has been Cancelled by the Unit, or the next Refused Offer booked date which is recorded after an Appointment/Visit that has been Cancelled by the Unit.

M201150 Replacement Appointment Booked Date The date that a Replacement Appointment/Visit was booked following the cancellation of an Appointment/Visit with the patient by the Health Care Provider. On SystmOne the Replacement Appointment Booked Date is defined as the next Appointment/Visit booked date after an appointment that has been Cancelled by the Unit.

MHS202 Care Activity

M202904 Care Activity Identifier The unique identifier for a Care Activity. SystmOne will automatically extract this item.

M202903 Care Contact Identifier The care contact identifier is used to uniquely identify the care contact within the health care provider. SystmOne will automatically extract this item.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 67 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M202908 Care Professional Local Identifier This is a unique local Care Professional identifier within a Health Care Provider. SystmOne automatically extracts this information.

M202020 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 recorded in the Duration field on the Consultation Activity dialog where the Care Activity option selected has been allocated an Option of “Clinical” in the configured list setup. Only one Care Activity can be recorded per Care Contact. If more than one Care Activity is captured within the Care Contact, then this will not be extracted into the MHSDS. If the user wishes to record multiple Activities within a single Care Contact (i.e. Appointment/Visit), the user should select the Next button to start a new consultation. For each additional consultation, an Activity Type should be selected by clicking Add on the Activities box on the Event Details dialog. This allows Observations, Findings and Procedures to be linked to the appropriate activity within a Care Contact. Each additional consultation must be linked to Care Contact (Appointment/Visit) via the New Journal or Link Consultation to Contact dialog. If the consultation has is not linked to the appointment at the time of extraction, then that Care Activity will not be flowed in the Care Contact table.

M202110 Coded Procedure and Procedure Status (SNOMED CT) A unique identifier for a finding from a specific clinical terminology. Any CTV3 Read codes recorded during a care contact from the Operations, Procedures and Interventions folder of the Read Code Browser, where the contact has a Care Activity of type ‘Clinical’ captured, will be extracted in this field and mapped to their SNOMED CT equivalent. If more than one Read code is recorded during the Care Contact, the Care Activity duration will be divided equally between the codes.

M202050 Finding Scheme in Use This is the clinical coding scheme that is in use for findings recorded during a Care Activity. SystmOne will automatically extract this information.

National Code Description

03 Read Coded Clinical Terms Version 3 (CTV3)

M202060 Coded Finding (Coded Clinical Entry) A unique identifier for a finding from a specific clinical terminology. Any Read codes recorded during a Care Contact from the Clinical Findings folder of the Read Code Browser will be extracted in this field. If more than one Read code is recorded during the Care Contact, the Care Activity duration will be divided equally between the codes.

M202070 Observation Scheme in Use This is the clinical coding scheme that is in use for observations recorded during a Care Activity. SystmOne will automatically extract this information.

National Code Description

02 Read Coded Clinical Terms Version 3 (CTV3)

M202080 Coded Observation (Clinical Terminology) A unique identifier for an observation from a specific clinical terminology. Any Read codes recorded during a Care Contact will be extracted in this field. If more than one Read code is recorded during the Care Contact, the Care Activity duration will be divided equally between the codes.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 68 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M202090 Observation Value The numeric value resulting from a Coded Observation. This is recorded in SystmOne by entering a numeric value for any numeric CTV3 Read codes recorded during a consultation.

M202100 UCUM Unit of Measurement The unit of measurement used to measure the result of a clinical observation. This is extracted from the Units field when recording a Numeric Value in a Data Entry Template. MHS203 Other in Attendance

M203903 Care Contact Identifier The care contact identifier is used to uniquely identify the care contact within the health care provider. SystmOne will automatically extract this item.

M203010 Other Person in Attendance at Care Contact This is the other person in attendance with the patient at the care contact. To invite or record attendees in SystmOne, select Manage Attendees on the relevant appointment or visit and populate the Type of attendee field. SystmOne only extracts attendees who have been marked as Attended on the Attendees dialog. This dialog is automatically displayed when marking an appointment or visit as Finished.

National Code Extract Description SystmOne Configured List Option

Advocacy Role

01 Independent Advocate (Family Member) Independent Advocate (Family Member)

02 Independent Advocate (Independent Independent Advocate (Independent Person) Person)

03 Independent Mental Capacity Advocate Independent Mental Capacity Advocate (IMCA) (IMCA)

04 Independent Mental Health Advocate Independent Mental Health Advocate (IMHA) (IMHA)

05 Non Instructed Advocate Non Instructed Advocate

Non-Advocacy Role

10 Parent or relative Parent or relative

11 Friend or neighbour Friend or neighbour

12 Care Worker Care Worker

MHS204 Indirect Activity

M204902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 69 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M204905 Care Professional Team Local Identifier Care Professional Team Local Identifier is a unique local team ID within a Health Care Provider and will be assigned automatically by SystmOne based on the team selected in the Team field on the Referral In dialog.

M204010 Indirect Activity Date This is the date the Care Activity took place. This is recorded in the Date field on the Event Details dialog, where the Care Activity option selected has been allocated an Option of “Patient not present” in the configured list setup. Only one Care Activity of option of “Patient not present” can be recorded per contact. Only one Care Activity can be recorded per Care Contact. If more than one Care Activity is captured within the Care Contact, then this will not be extracted into the MHSDS. If the user wishes to record multiple Activities within a single contact, the user should select the Next button to start a contact. For each additional contact an Activity Type should be selected by clicking Add on the Activities box on the Event Details dialog, this needs to be of Option “Patient not present”. This allows Coded Procedures to be linked to the appropriate activity within a Contact.

M204020 Indirect Activity Time This is the time the Care Activity took place. This is recorded in the Time field on the Event Details dialog, where the Care Activity option selected has been allocated an Option of “Patient not present” in the configured list setup. Only one Care Activity of option of “Patient not present” can be recorded per contact. Only one Care Activity can be recorded per Care Contact. If more than one Care Activity is captured within the Care Contact, then this will not be extracted into the MHSDS. If the user wishes to record multiple Activities within a single contact, the user should select the Next button to start a contact. For each additional contact an Activity Type should be selected by clicking Add on the Activities box on the Event Details dialog, this needs to be of Option “Patient not present”. This allows Coded Procedures to be linked to the appropriate activity within a Contact.

M204030 Duration of Indirect Activity The duration of a care activity in minutes. This is recorded in the Duration field on the Consultation Activity dialog where the Care Activity option selected has been allocated an Option of “Patient not present” in the configured list setup. Only one Care Activity of option of “Patient not present” can be recorded per contact. If more than one Care Activity of option “Patient not present” is captured within the contact, then this will not be extracted into the MHSDS. If the user wishes to record multiple Activities within a single contact, the user should select the Next button to start a contact. For each additional contact an Activity Type should be selected by clicking Add on the Activities box on the Event Details dialog, this needs to be of Option “Patient not present”. This allows Coded Procedures to be linked to the appropriate activity within a Contact.

M204922 Organisation Identifier (Code of Commissioner) This is the ID of the organisation responsible for the GP Practice where the patient is registered at the time of the referral to the Service or Team, e.g. the Clinical Commissioning Group (CCG). In SystmOne this is the CCG code for the patient’s registered GP at the point of the patient’s referral. Where there is no registered GP Practice, SystmOne will generate a CCG code based on the patient’s address. Where there is no fixed address for the patient, SystmOne will use the Commissioning CCG ID of the team recorded for that referral. Where there is no Commissioning CCG ID for the team on the referral, the ID of the organisation responsible for the Mental Health Trust will be used.

M204908 Care Professional Local Identifier This is a unique local Care Professional identifier within a Health Care Provider. SystmOne automatically extracts this information.

M204070 Coded Procedure and Procedure Status (SNOMED CT) A unique identifier for a finding from a specific clinical terminology. Any CTV3 Read codes recorded during a care contact from the Operations, Procedures and Interventions folder of the Read Code Browser will be extracted

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 70 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

in this field and mapped to their SNOMED CT equivalent, where the Care Activity option selected has been allocated an Option of “Patient not present” in the configured list setup. If more than one Read code is recorded during the contact, the Care Activity duration will be divided equally between the codes.

M204080 Finding Scheme in Use This is the clinical coding scheme that is in use for findings recorded during a Care Activity. SystmOne will automatically extract this information.

National Code Description

04 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®)

M204090 Coded Finding (Coded Clinical Entry) A unique identifier for a finding from a specific clinical terminology. Any Read codes recorded during a Care Contact from the Clinical Findings folder of the Read Code Browser will be extracted in this field and mapped to their SNOMED CT equivalent. If more than one Read code is recorded during the Care Contact, the Care Activity duration will be divided equally between the codes.

Data Group MHS301: Group Session

M301010 Group Session Identifier The Group Session identifier is used to uniquely identify the Group Session within the Healthcare Provider. SystmOne will automatically extract this information.

M301020 Group Session Date The date that a Group Session took place, or if cancelled, was scheduled to take place. This can be recorded in the Activity Date field on the New Staff Activity dialog.

M301922 Organisation Identifier (Code of Commissioner) This is the organisation identifier of the organisation commissioning health care. This is the CCG Code of the respective Mental Health trusts.

M301030 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. This is recorded in the Duration field on the New Staff Activity dialog.

M301040 Group Session Type Code (Mental Health) This is the type of Group Session provided by the Community Health Service. This can be recorded on the Contact Type field on the New Staff Activity dialog.

National Code Extract Description SystmOne Configured List Option

01 General Health Promotion Session General Health Promotion Session

02 Telephone Support Session Telephone Support Session

03 Therapeutic Group Session Therapeutic Group Session

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 71 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M301050 Number of Group Session Participants The number of persons who participated in the Group Session excluding the care professionals. This is recorded in the Attendees field on the New Staff Activity dialog.

M301909 Activity Location Type Code The type of physical location where patients are seen, where services are provided, or from which requests for services are sent. This can be recorded in the Location field on the New Staff Activity dialog.

National Code Extract Description SystmOne Configured List Option

Patient main residence or related location

A01 Patient's Home Home of Patient

A02 Carer's Home Carer's Home

A03 Patient's Workplace Patient's Workplace

A04 Other Patient Related Location Other patient related location

Health Centre premises

B01 Primary Care Health Centre Primary Care Centre

B02 Polyclinic Polyclinic

General Practitioner and Ophthalmic Medical Practitioner Premises

C01 General Medical Practitioner Practice GP Surgery

C02 Dental Practice General Dental Practice

C03 Ophthalmic Medical Practitioner premises Ophthalmic Medical Practitioner premises

Walk In Centres, Out of Hours Premises and Emergency Community Dental Services

D01 Walk In Centre Walk In Centre

D02 Out of Hours Centre Out of Hours Centre

D03 Emergency Community Dental Service Emergency Community Dental Service

Locations on Hospital Premises

E01 Out-Patient Clinic Out-patient clinic

E02 Ward Ward

E03 Day Hospital Day Hospital

E04 Accident and Emergency or Minor Injuries A & E; Minor Injuries Unit Department

E99 Other departments Other departments

Hospice premises

F01 Hospice Hospice

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 72 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

Nursing and Residential Homes

G01 Care Home Without Nursing Care Home without Nursing

G02 Care Home With Nursing Care Home with Nursing

G03 Children’s Home Children’s Home

G04 Integrated Care Home Without Nursing and Care Integrated Care Home Without Home With Nursing Nursing and Care Home With Nursing

Day Centre premises

H01 Day Centre Day Centre

Resource Centre premises

J01 Resource Centre Resource Centre

Dedicated Facilities for Children and Families

K01 Sure Start Children’s Centre Sure Start Children’s Centre

K02 Child Development Centre Child Development Centre

Educational, Childcare and Training Establishments

L01 School School

L02 Further Education College Further Education College

L03 University University

L04 Nursery Premises Nursery Premises

L05 Other Childcare Premises Other Childcare Premises

L06 Training Establishments Training Establishments

L99 Other Educational Premises Other educational premises

Justice and Home Office premises

M01 Prison Prison

M02 Probation Service Premises Probation Service premises

M03 Police Station / Police Custody Suite Police Station / Police Custody Suite

M04 Young Offenders Institute Young Offenders Institution

M05 Immigration Removal Centre Immigration Centre

M06 Young Offender Institution (15-17) Young Offender Institution (15-17)

M07 Young Offender Institution (18-21) Young Offender Institution (18-21)

Public locations

N01 Street or other public open space Street or other public open space

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 73 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

N02 Other publicly accessible area or building Other publicly accessible area or building

N03 Voluntary or charitable agency premises Voluntary or charitable agency premises

N04 Dispensing Optician premises Dispensing Optician premises

N05 Dispensing Pharmacy premises Dispensing Pharmacy premises

Other Locations

X01 Other locations not elsewhere classified Other locations not elsewhere classified

M301921 Organisation Site Identifier (Of Treatment) This is the organisation site identifier for the organisation site where the patient was treated. This will be extracted using the unit’s ODS code. The unit’s ODS code is recorded in the ODS Code field of the Community National Data Extracts Organisation Preference (Setup>Users & Policy>Organisation Preferences>Clinical Policy>Community National Data Extracts).

M301908 Care Professional Local Identifier This is a unique local Care Professional identifier within a Health Care Provider. SystmOne automatically extracts this information. This will be output for the relevant staff member if the Staff Member radio button is selected on the New Staff Activity dialog.

M301913 Service or Team Type referred to (Mental Health) This is the type of team associated with the activity. For this field SystmOne will extract the type of team set against the team if the Team radio button is selected on the New Staff Activity dialog. The team type is set by going to Setup > Users & Policy > Configure Teams.

National Code Extract Description SystmOne Configured List Option

General Mental Health Services

A01 Day Care Service Day Care Service

A02 Crisis Resolution Team/Home Treatment Crisis Resolution Team/Home Treatment Service Service

A03 Crisis Resolution Team Crisis Resolution Team

A04 Home Treatment Service Home Treatment Service

A05 Primary Care Mental Health Service Primary Care Mental Health Service

A06 Community Mental Health Team – Functional Community Mental Health Team – Functional

A07 Community Mental Health Team – Organic Community Mental Health Team – Organic

A08 Assertive Outreach Team Assertive Outreach Team

A09 Rehabilitation & Recovery Service Rehabilitation & Recovery Service

A10 General Psychiatric Service General Psychiatric Service

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 74 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

A11 Psychiatric Liaison Service Psychiatric Liaison Service

A12 Psychotherapy Service Psychotherapy Service

A13 Psychological Therapy Service (non IAPT) Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis Early Intervention Team for Psychosis

A15 Young Onset Dementia Team Young Onset Dementia Team

A16 Personality Disorder Service Personality Disorder Service

A17 Memory Services/Clinic Memory Services/Clinic

A18 Single Point of Access Service Single Point of Access Service

A19 24/7 Crisis Response Line 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service Health Based Place Of Safety Service

Forensic Services

B01 Forensic Mental Health Service Forensic Mental Health Service

B02 Forensic Learning Disability Service Forensic Learning Disability Service

Specialist Mental Health Services

C01 Autistic Spectrum Disorder Service Autistic Spectrum Disorder Service

C02 Peri-Natal Mental Illness Service Peri-Natal Mental Illness Service

C03 Eating Disorders/Dietetics Service Eating Disorders/Dietetics Service

C04 Neurodevelopment Team Neurodevelopment Team

C05 Paediatric Liaison Service Paediatric Liaison Service

C06 Looked After Children Service Looked After Children Service

C07 Community Young Offenders Service Community Young Offenders Service

C08 Acquired Brain Injury Service Acquired Brain Injury Service

C09 Community Eating-Disorder Service for Children Community Eating-Disorder Service for and Young People Children and Young People

Other Mental Health Services

D01 Substance Misuse Team Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service Prison Psychiatric Inreach Service

D04 Asylum Service Asylum Service

D05 Individual Placement and Support Service Individual Placement and Support Service

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 75 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

Learning Disability Services

E01 Community Team for Learning Disabilities Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service Epilepsy/Neurological Service

E03 Specialist Parenting Service Specialist Parenting Service

E04 Enhanced/Intensive Support Service Enhanced/Intensive Support Service

Other

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

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

M301907 NHS Service Agreement Line Number A number to provide a unique identifier for a line within a NHS Service Agreement. This can be recorded on the Payment By Results Contract Setup screen by selecting New Contract.

MHS401 Mental Health Act Legal Status

M401914 Mental Health Act Legal Status Classification Assignment Period Identifier A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. SystmOne automatically extracts this information when a Section has been recorded for the patient. A Mental Health Act Legal Status Classification Period covers the entire time that the patient was detained under a specific section of the MHA, including any renewals. Where the patient becomes subject to a Community Treatment Order (CTO) or a Conditional Discharge (CD) associated with a section recorded in the MHA Legal Status Classification Period table the MHA Legal Status Classification Period should remain open for the duration of the CTO or CD.

M401901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M401010 Start Date (Mental Health Act Legal Status Classification Assignment Period) The start date of a patient’s section. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Start field.

M401020 Start Time (Mental Health Act Legal Status Classification Assignment Period) The start time of a patient’s section. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Start field.

M401030 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. This is the Section Start Reason recorded on the New Section dialog. This can be recorded in the patient record by right clicking on the MHA node, and selecting New Section.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 76 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Description SystmOne Configured List Option

01 Change in Mental Health Act Legal Status Change in legal status (including from Classification Code (including from informal) informal)

04 Transfer from other Health Care Provider Transfer from other provider

M401040 Expiry Date (Mental Health Act Legal Status Classification Assignment Period) The current expiry date of a patient’s section or an associated CTO or CD. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Expires field.

M401050 Expiry Time (Mental Health Act Legal Status Classification Assignment Period) The current expiry time of a patient’s section or an associated CTO or CD. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Expires field.

M401060 End Date (Mental Health Act Legal Status Classification Assignment Period) The current end date of a patient’s section or an associated CTO or CD. This can be recorded in the patient record by clicking on the green cross for an existing Section, selecting End and recording the Date field on the End Section dialog. Any associated CTO or CD should run concurrently with the underlying MHA Legal Status Classification Period with a MHA Legal Status Classification Period End Date that is the same as or after the CTO or CD End Date.

M401070 End Time (Mental Health Act Legal Status Classification Assignment Period) The current end time of a patient’s section or an associated CTO or CD. This can be recorded in the patient record by clicking on the green cross for an existing Section, selecting End and recording the Time field on the End Section dialog. Any associated CTO or CD should run concurrently with the underlying MHA Legal Status Classification Period with a MHA Legal Status Classification Period End Date that is the same as or after the CTO or CD End Date.

M401080 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. This can be recorded in the patient record by clicking on the green cross for an existing section, selecting End and recording the Outcome field on the End Section dialog.

National Code Description SystmOne Configured List Option

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

04 Transfer to other Health Care Provider Transfer to other provider

05 Death of patient Death of patient

M401090 Mental Health Act Legal Status Classification Code A code to identify the classification of Mental Health Act Legal Status. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Section Type field.

National Description SystmOne Hardcoded Option Code

01 Informal The patient will not have a current section

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 77 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Description SystmOne Hardcoded Option Code

02 Formally detained under Mental Health Act Section 2 – Admission for assessment Section 2

03 Formally detained under Mental Health Act Section 3 – Admission for treatment Section 3

04 Formally detained under Mental Health Act Section 4 – Admission for assessment in Section 4 cases of emergency

05 Formally detained under Mental Health Act Section 5(2) – Application in respect of Section 5 (2) patient already in hospital (Doctors holding powers)

06 Formally detained under Mental Health Act Section 5(4) – Application in respect of Section 5 (4) patient already in hospital (Nurses holding powers)

07 Formally detained under Mental Health Act Section 35 – Remand to hospital for report Section 35 on accused’s mental condition

08 Formally detained under Mental Health Act Section 36 – Remand of accused person to Section 36 hospital for treatment

09 Formally detained under Mental Health Act Section 37/41 – Power of higher courts to Section 37 with 41 restrictions restrict discharge from hospital

10 Formally detained under Mental Health Act Section 37- Power of courts to order Section 37 hospital admission

12 Formally detained under Mental Health Act Section 38 – Interim hospital orders Section 38

13 Formally detained under Mental Health Act Section 44 – Committal to hospital under Section 44 section 43

14 Formally detained under Mental Health Act Section 46 – Persons ordered to be kept in Section 46 custody during Her Majesty’s pleasure

15 Formally detained under Mental Health Act Section 47/49 – Transfer of prisoner to Section 47 with 49 restrictions hospital/restrictions on hospital discharge

16 Formally detained under Mental Health Act Section 47 – Removal to hospital of Section 47 persons serving sentences of imprisonment, etc.

17 Formally detained under Mental Health Act Section 48/49 – Removal to hospital of Section 48 with 49 restrictions other prisoners – Restriction on discharge of prisoner

18 Formally detained under Mental Health Act Section 48 – Removal to hospital of other Section 48 prisoners

19 Formally detained under Mental Health Act Section 135 – Warrant to search for and Section 135 remove patients

20 Formally detained under Mental Health Act Section 136 – Mentally disordered persons Section 136 found in public places

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 78 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Description SystmOne Hardcoded Option Code

32 Formally detained under other acts Other acts

35 Subject to guardianship under Mental Health Act Section 7 - Application for guardianship Section 7

36 Subject to guardianship under Mental Health Act Section 37- Power of courts to order Section 37 guardianship

37 Formally detained under Mental Health Act Section 45A- Power of higher courts to Section 45A (Limitation direction in force) direct hospital admission (Limitation direction in force)

38 Formally detained under Mental Health Act Section 45A- Power of higher courts to Section 45A (Limitation direction ended) direct hospital admission (Limitation direction ended)

M401100 Mental Health Act 2007 Mental Category The primary reason for the detention of patients. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, in the Category field.

National Code Description SystmOne Hardcoded Option

A Mental disorder (Learning Disability not present Mental disorder (Learning Disability not or not primary reason for using Act) present or not primary reason for using Act)

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

8 Not applicable (Not detained) Not applicable (Not detained)

9 Not known Not known

MHS402 Mental Health Responsible Clinician Assignment

M402914 Mental Health Act Legal Status Classification Assignment Period Identifier A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. SystmOne automatically extracts this information when a Section has been recorded for the patient.

M402010 Start Date (Mental Health Responsible Clinician Assignment Period) The start date of an assignment of a Mental Health Responsible Clinician to a patient. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section, and recording information in the Clinician Became Responsible fields.

M402908 Care Professional Local Identifier (Extended) This number uniquely identifies the Care Professional within the Health Care Provider system. SystmOne will extract this information automatically.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 79 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M402020 End Date (Mental Health Responsible Clinician Assignment Period) The end date of an assignment of a Mental Health Responsible Clinician to a patient. This is extracted from the end date of a Section as you cannot record previous clinicians for a Section.

MHS403 Conditional Discharge

M403914 Mental Health Act Legal Status Classification Assignment Period Identifier A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. SystmOne automatically extracts this information when a Section has been recorded for the patient.

M403010 Start Date (Mental Health Conditional Discharge) The start date of the Mental Health Conditional Discharge Period. A Conditional Discharge is recorded by clicking on the MHA node, and selecting New Section and selecting a Section Type of Section 42 or Section 73. When recording a CD, the user will be prompted to link it to a current section, or record a backdated section to link the CD to. Any Conditional Discharges that have no underlying section will not be output in this table.

M403020 End Date (Mental Health Conditional Discharge) The end date of the Mental Health Conditional Discharge Period. The current end date of a patient’s section. This can be recorded in the patient record by clicking on the green cross for an existing Section 42 or Section 73, selecting End and recording the Date field on the End Section dialog.

M403030 Mental Health Conditional Discharge End Reason The reason a Mental Health Conditional Discharge Period ended. This can be recorded by selecting End on a Section 42 or Section 73 and recording the Outcome field.

M403040 Mental Health Absolute Discharge Responsibility The body or person responsible for granting mental health absolute discharge. This is the Discharge Method that is recorded on the End Section dialog when the Outcome for a Section 42 or Section 73 is mapped to the national code of 01- Mental Health Absolute Discharge.

National Code Extract Description SystmOne Configured List Option

01 Mental Health Tribunal Usual place of residence

02 Secretary of State Temporary place of residence

MHS404 Community Treatment Order

M404914 Mental Health Act Legal Status Classification Assignment Period Identifier A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. SystmOne automatically extracts this information when a section has been recorded for the patient.

M404010 Start Date (Community Treatment Order) 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). This can be recorded in the patient record by right clicking on the MHA node, selecting New Section and recording a Section Type of Section 17A. CTOs can also be recorded by selecting Suspend on a patient’s current section and completing the New Section Period dialog. When recording a CTO via the New Section dialog, the user will be prompted to link it to a current section, or record a backdated section to link the CTO to. Any CTOs that have no underlying section will not be output in this table.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 80 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M404020 Expiry Date (Community Treatment Order) 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. This can be recorded in the patient record by right clicking on the MHA node, selecting New Section and recording a Section Type of Section 17A. CTOs can also be recorded by selecting Suspend on a patient’s current section and completing the New Section Period dialog.

M404030 End Date (Community Treatment Order) The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007). This can be recorded in the patient record by clicking on the green cross for an existing Section 17A, selecting End and recording the Date field on the End Section dialog. CTOs can also be recorded by selecting Suspend on a patient’s current section and completing the New Section Period dialog.

M404040 Community Treatment Order End Reason The reason for the termination of a period of a Community Treatment Order. This can be recorded by selecting End on a Section 17A and recording the Outcome field.

MHS405 Community Treatment Order Recall

M405914 Mental Health Act Legal Status Classification Assignment Period Identifier A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period. SystmOne automatically extracts this information when a Section has been recorded for the patient.

M405010 Start Date (Community Treatment Order Recall) The start date of a patient’s CTO Recall. This can be recorded in the patient record by clicking on the green cross icon next to a Section 17A and selecting New Recall.

M405020 Start Time (Community Treatment Order Recall) The start time of a patient’s CTO Recall. This can be recorded in the patient record by clicking on the green cross icon next to a Section 17A and selecting New Recall.

M405030 End Date (Community Treatment Order Recall) The end date of a patient’s CTO Recall. This can be recorded in the patient record by clicking on the green cross icon next to a Section 17A and selecting New Recall, or by pressing Amend next to an existing Recall.

M405040 End Time (Community Treatment Order Recall) The end time of a patient’s CTO Recall. This can be recorded in the patient record by clicking on the green cross icon next to a Section 17A and selecting New Recall, or by pressing Amend next to an existing Recall.

MHS501 Hospital Provider Spell

M501920 Hospital Provider Spell Number A unique identifier for each Hospital Provider Spell for a Health Care Provider. This will be generated automatically by SystmOne.

M501902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 81 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M501010 Start Date (Hospital Provider Spell) This is the start date of the Hospital Provider Spell. This is recorded in the Admitted Time field on the Admit patient dialog.

M501020 Start Time (Hospital Provider Spell) This is the start time of the Hospital Provider Spell. This is recorded in the Admitted Time field on the Admit patient dialog.

M501030 Source of Admission Code (Hospital Provider Spell) This is the source of admission to a Hospital Provider Spell when the patient is in a Hospital site. This is recorded in the Admission source field on Admit patient dialog.

National Code Extract Description SystmOne Configured List Option

19 Usual place of residence unless listed below, for Usual place of residence 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 Temporary place of residence resident elsewhere (e.g. hotels, residential educational establishments)

39 Penal establishments, Court, or Police Station / Penal establishment, court, or police Police Custody Suite station

40 Penal Establishment Penal Establishment

41 Court Court

42 Police Station/Police Custody Suite Police Station/Police Custody Suite

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

51 NHS other Hospital Provider – WARD for NHS ward for general patients, younger general PATIENTS or the younger physically physically disabled or A&E disabled or A&E department

52 NHS other Hospital Provider – WARD for NHS other ward for maternity patients or maternity PATIENTS or Neonates neonates

53 NHS other Hospital Provider – WARD for NHS ward for mentally ill or learning PATIENTS who are mentally ill or have Learning disabilities patients Disabilities

54 NHS run Care Home NHS run care home

65 Local Authority residential accommodation i.e. Local Authority residential where care is provided accommodation

66 Local Authority foster care Local Authority foster care

85 Non-NHS (other than Local Authority) run Care Non-NHS run care home Home

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 82 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

87 Non NHS run hospital Non-NHS run hospital

88 Non – NHS (other than Local Authority) run Non-NHS run Hospice Hospice

98 Not applicable Not Applicable

99 Not known: a validation error Not Known: a validation error

M501040 Admission Method Code (Hospital Provider Spell) This is the method of admission for the Hospital Provider Spell. This is recorded in the Admission Method on the Admit Patient dialog.

National Code Extract Description SystmOne Configured List Option

Elective Admission

11 Waiting list Waiting list

12 Booked Booked

13 Planned Planned

Emergency Admission

21 Accident and emergency, or dental casualty A&E or dental casualty department department of the Health Care Provider

22 General Practitioner after a request has been General practitioner made direct to the Health Care Provider (i.e. not through a bed bureau) by a General Practitioner or deputy

23 Bed Bureau Bed Bureau

24 Consultant clinic of this or another Health Care Consultant clinic Provider

25 Admission via Mental Health Crisis Resolution Admission via Mental Health Crisis Team Resolution Team

2A Accident and Emergency Department of another Accident and Emergency Department of provider where the PATIENT had not been another provider where the PATIENT admitted had not been admitted

2B Transfer of an admitted PATIENT from another Transfer of an admitted PATIENT from Hospital Provider in an emergency another Hospital Provider in an emergency

2D Other emergency admission Other emergency

Other Admission

81 Transfer of any admitted patient from other Non-emergency transfer hospital provider other than in an emergency. This does not include admissions to high security psychiatric hospitals

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 83 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

98 Not applicable Not applicable

99 Not Known: a validation error Not Known: a validation error

M501100 Postcode of Main Visitor This is the postcode of the patient’s main visitor. A patient’s main visitor can be recorded by recording a new relationship on the Groups & Relationships node and selecting the Main Visitor option on the New Relationship dialog.

M501090 Planned Discharge Date (Hospital Provider Spell) This is the planned date the patient is due to be discharged from hospital. For this item, SystmOne will extract the most recently recorded date in the Expected discharge date field in the Manage Discharge Status dialog with the Discharge date definite box ticked.

M501150 Planned Discharge Destination Code (Hospital Provider Spell) This is the planned destination of a patient on completion of a Hospital Provider Spell. This is recorded in the Expected Discharge Destination field on the Manage EDD and Discharge Delays dialog.

National Code Extract Description SystmOne Configured List Option

19 Usual place of residence unless listed below, for Usual place of residence 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 Temporary place of residence resident elsewhere (includes hotel, residential educational establishment)

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

37 Court Court

38 Penal establishment or police station Penal establishment or police station

48 High Security Psychiatric Hospital, Scotland High Security Psychiatric Hospital, Scotland

49 NHS other hospital provider - high security NHS other hospital provider - high psychiatric accommodation security psychiatric accommodation

50 NHS other hospital provider - medium secure NHS other hospital provider - medium unit secure unit

51 NHS other hospital provider - ward for general NHS other hospital provider - ward for PATIENTS or the younger physically disabled general PATIENTS or the younger physically disabled

52 NHS other hospital provider - ward for maternity NHS other hospital provider - ward for PATIENTS or neonates maternity PATIENTS or neonates

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 84 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

53 NHS other hospital provider - ward for NHS other hospital provider - ward for PATIENTS who are mentally ill or have learning PATIENTS who are mentally ill or have disabilities learning disabilities

54 NHS run Care Home NHS run Care Home

65 Local Authority residential accommodation ie Local Authority residential where care is provided accommodation ie where care is provided

66 Local Authority foster care Local Authority foster care

79 Not applicable - PATIENT died or still birth Not applicable - PATIENT died or still birth

84 Non-NHS run hospital - medium secure unit Non-NHS run hospital - medium secure unit

85 Non-NHS (other than Local Authority) run Care Non-NHS (other than Local Authority) Home run Care Home

87 Non-NHS run hospital Non-NHS run hospital

88 Non-NHS (other than Local Authority) run Non-NHS (other than Local Authority) Hospice run Hospice

98 Not applicable Not applicable

99 Not known Not known

M501050 Discharge Date (Hospital Provider Spell) This is the date the patient was discharged. This is recorded in the Discharged field on the Discharge Patient dialog.

M501060 Discharge Time (Hospital Provider Spell) This is the time the patient was discharged. This is recorded in the Discharged field on the Discharge Patient dialog.

M501070 Discharge Method Code (Hospital Provider Spell) The Method set when the patient is discharged on the Discharge Patient dialog.

National Code Extract Description SystmOne Configured List Option

1 Patient discharged on clinical advice or with On clinical advice or with clinical consent clinical consent

2 Patient discharged him/herself or was Self or by a relative or advocate discharged by a relative or advocate

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

4 Patient died Patient died

6 Patient discharged him/herself Patient discharged by him/herself

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 85 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

7 Patient discharged by a relative or advocate Patient discharged by a relative or advocate

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

9 Not known: a validation error Not known

M501080 Discharge Destination Code (Hospital Provider Spell) The Destination recorded when the patient is discharged on the Discharge Patient dialog.

National Code Extract Description SystmOne Configured List Option

19 Usual place of residence unless listed below, for Usual place of residence 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 Temporary place of residence resident elsewhere (includes hotel, residential educational establishment)

30 Repatriation from high security psychiatric Repatriation from high security accommodation in an NHS Hospital Provider psychiatric accommodation in an NHS (NHS Trust) hospital provider

37 Court Court

38 Penal establishment or police station Penal establishment or police station

48 High Security Psychiatric Hospital, Scotland High Security Psychiatric Hospital, Scotland

49 NHS other hospital provider - high security NHS high security psychiatric psychiatric accommodation accommodation

50 NHS other hospital provider - medium secure NHS medium secure unit unit

51 NHS other hospital provider - ward for general NHS ward for general patients or the PATIENTS or the younger physically disabled younger physically disabled

52 NHS other hospital provider - ward for maternity NHS ward for maternity patients or PATIENTS or neonates neonates

53 NHS other hospital provider - ward for NHS ward for patients who are mentally PATIENTS who are mentally ill or have learning ill or have learning disabilities disabilities

54 NHS run Care Home NHS run care home

65 Local Authority residential accommodation i.e. Local Authority residential where care is provided accommodation

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 86 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

66 Local Authority foster care Local Authority foster care

79 Not applicable - PATIENT died or still birth N/A - patient died or still birth

84 Non-NHS run hospital – medium secure unit Non-NHS hospital - medium secure unit

85 Non-NHS (other than Local Authority) run Care- Non-NHS run care home Home

87 Non-NHS run hospital Non-NHS run hospital

88 Non-NHS (other than Local Authority) run Non-NHS run Hospice Hospice

98 Not applicable Not applicable

99 Not known Not known

M501170 Postcode of Discharge Destination (Hospital Provider Spell) The postcode of the address of a patient’s destination on completion of a Hospital Provider Spell. This is recorded in the Discharge address field of the Record Discharge Detail dialog or Discharge Patient dialog.

MHS502 Ward Stay

M502915 Ward Stay Identifier A unique identifier allocated for each Ward Stay during the hospital provider spell. This will be generated automatically by SystmOne.

M502920 Hospital Provider Spell Number This is the unique identifier for each Hospital Provider Spell. This will be generated automatically by SystmOne.

M502010 Start Date (Ward Stay) The start date of the ward stay. This is the date the patient was admitted to the ward or transferred from another ward and can be recorded on either the Admitted Time field of the Admit Patient dialog or the Start of Episode field on the Internal Transfer dialog (Inpatient Overview > Transfer > Internal Transfer).

M502020 Start time (Ward Stay) The start time of the ward stay. This is the time the patient was admitted to the ward or transferred from another ward and can be recorded on either the Admitted Time field of the Admit Patient dialog or the Start of Episode field on the Internal Transfer dialog Inpatient Overview > Transfer > Internal Transfer).

M502030 End Date (Ward Stay) The end date of the ward stay. This is date the patient was discharged from the ward or transferred from another ward. This can be recorded on the Discharged field of the Discharge Patient Dialog (Inpatient Overview > Discharge > Discharge Patient) or the Start of Episode field on the Internal Transfer dialog Inpatient Overview > Transfer > Internal Transfer).

M502040 End Time (Ward Stay) The end time of the ward stay. This is the time the patient was discharged from the ward or transferred from another ward. This can be recorded on the Discharged field of the Discharge Patient Dialog (Inpatient Overview > Discharge > Discharge Patient) or the Start of Episode field on the Internal Transfer dialog Inpatient Overview > Transfer > Internal Transfer).

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 87 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M502921 Organisation Site Identifier (Of Treatment) This is the organisation site identifier for the organisation site where the patient was treated. This will be extracted using the unit’s ODS code. The unit’s ODS code is recorded in the ODS Code field of the Community National Data Extracts Organisation Preference (Setup>Users & Policy>Organisation Preferences>Clinical Policy>Community National Data Extracts).

M502050 Ward Setting Type (Mental Health) The type of ward setting for a patient during a Hospital Provider Spell. This is setup against the ward in the Broad patient group on the Ward Settings tab of the Location Details dialog.

National Code Extract Description SystmOne Option

01 Child and Adolescent Mental Health Ward Children and Adolescents with mental illness

02 Paediatric Ward Paediatrics

03 Adult Mental Health Ward Adults with mental illness

04 Non Mental Health Ward Patients without mental illness

05 Learning Disabilities Ward Patients with learning disabilities

06 Older People's Mental Health Ward Older people with mental illness

M502110 Intended Age Group (Mental Health) The age group of patients intended to use a ward indicated in the operational plan. This is set using the Intended Age Group field when amending the location in Location Management.

National Code Extract Description SystmOne Configured List Option

10 Child only Child only

11 Adolescent only Adolescent only

12 Child and Adolescent Child and Adolescent

13 Adult only Adult only

14 Older Adult only Older Adult only

15 Adult and Older Adult Adult and Older Adult

99 Any age Any age

M502060 Sex of Patients Code This is the intended sex of the patient for the ward. The intended sex of patients for the ward can be configured against the ward in Location Management. If no sex is selected, this will be output as Not Specified. This is set using the Gender field when amending the location in Location Management.

National Code Extract Description SystmOne Option

1 Males Male

2 Females Female

8 Not specified Not specified

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 88 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M502080 Intended Clinical Care Intensity Code (Mental Health) The intended intensity of care for the ward in which the person is placed. This is captured in the Care Intensity field on the Ward Settings tab of the Location Details dialog.

National Code Extract Description SystmOne Option

Mental Illness Mental Illness

51 For intensive care - specially designated ward For intensive care: designated ward for for patients needing containment and more containment and intensive management intensive management (e.g. Psychiatric of patients Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where a patient may require one-to-one nursing whilst on a standard ward

52 For short stay - patients intended to stay for less For short stay: patients intended to stay than a year less than a year

53 For long stay - patients intended to stay a year For long stay: patients intended to stay a or more year a more

Learning Disabilities Learning Disabilities

61 Designated or interim secure unit Designated or interim secure unit

62 Patients intending to stay less than a year Patients intending to stay less than a year

63 Patients intending to stay a year or more Patients intending to stay a year or more

M502090 Ward Security Level

The level of security for a ward. This is recorded in the Security level field on the Location tab of the Location Details dialog in Location Management.

National Code Extract Description SystmOne Option

0 General (non-secure) General (non-secure)

1 Low Secure Low Secure

2 Medium Secure Medium Secure

3 High Secure High Secure

M502100 Locked Ward Indicator Whether a ward has been locked or not. This is recorded in Location Management by right clicking on the ward and selecting a New Attribute of ‘Locked Ward.’

M502120 Mental Health Admitted Patient Classification The classification of the admitted patient during a Ward Stay. This field is not currently supported by SystmOne.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 89 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M502140 Ward Code A unique identification of a ward within a Health Care Provider. This is set in the CDS Site code field for the ward on the Location Management screen.

MHS503 Assigned Care Professional

M503920 Hospital Provider Spell number This is the unique identifier for each Hospital Provider Spell. This will be generated automatically by SystmOne.

M503908 Care Professional local identifier This is a unique local Care Professional identifier within a Health Care Provider. This will be generated automatically by SystmOne.

M503010 Start Date (Care Professional Admitted Care Episode) This is the start date of an assignment of a Care Professional responsible for the care of the patient. In SystmOne this is recorded either via a Consultant Episode, or the patient has a responsibility of Nurse. Nurse responsibility start dates are recorded in the Responsibility start field of the Add New Responsible Party dialog. This is accessed through the Ward View or In-Patient Overview by right-clicking on a patient, Responsibility>Add Other Responsibility. Consultant Episode start dates are recorded in the Start of episode field on the Amend Consultant Episode dialog. This is accessed through the Ward View or In-Patient Overview by right-clicking on a patient, Clinical>Amend Consultant Episode Details.

M503020 End Date (Care Professional Admitted Care Episode) This is the end date of an assignment of a Care Professional responsible for the care of the patient. In SystmOne this is recorded either via a Consultant Episode, or the patient has a responsibility of Nurse. Nurse responsibility end dates are recorded in the Responsibility end date field of the Enter responsibility end date dialog. This is accessed through the Ward View or In-Patient Overview by right-clicking on a patient, Responsibility>Manage Responsible Parties selecting a responsible party and selecting End a responsible party icon. Consultant Episode end dates are recorded in the End field on the Consultant Episode dialog. This is accessed through the Ward View or In-Patient Overview by right-clicking on a patient, Clinical>Amend Admission and selecting the Amend or Add icons on the Amend Hospital Admission dialog.

M503040 Treatment Function Code (Mental Health) This is the treatment function under which the patient is treated. This is recorded when the patient is admitted on the Admit Patient dialog.

National Code Extract Description SystmOne Configured List Option

319 Respite care Respite care

700 Learning Disability Learning disability

710 Adult Mental illness Adult mental illness

711 Child and Adolescent Psychiatry Child and adolescent psychiatry

712 Forensic psychiatry Forensic psychiatry

713 Psychotherapy Psychotherapy

715 Old age psychiatry Old age psychiatry

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 90 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

720 Eating Disorders Eating disorders

721 Addiction Services Addiction services

722 Liaison Psychiatry Liaison psychiatry

723 Psychiatric Intensive Care Psychiatric intensive care

724 Perinatal Psychiatry Perinatal psychiatry

725 Mental Health Recovery and Rehabilitation Mental Health Recovery and Service Rehabilitation Service

726 Mental Health Dual Diagnosis Service Mental Health Dual Diagnosis Service

727 Dementia Assessment Service Dementia Assessment Service

MHS504 Mental Health Delayed Discharge

M504920 Hospital Provider Spell number This is the unique identifier for each Hospital Provider Spell. This will be generated automatically by SystmOne.

M504010 Start Date (Mental Health Delayed Discharge Period) The date the patient was clinically ready for discharge but external factors prevent the discharge taking place. This is the start date of the delay recorded on the Add Discharge Delay dialog.

M504020 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. This is the date the discharge delay is ended on the Manage EDD and Discharge Delays dialog.

M504030 Mental Health Delayed Discharge Reason The reason that a patient was not able to be discharged despite being medically ready for discharge. This is captured in the Reason field of the Add Discharge Delay dialog.

National Code Extract Description SystmOne Configured List Option

A2 Awaiting care coordinator allocation Awaiting care coordinator allocation

B1 Awaiting public funding Awaiting public funding

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

D1 Awaiting Care Home Without Nursing placement Awaiting residential care home or availability placement

D2 Awaiting Care Home With Nursing placement or Awaiting nursing care home placement availability

E1 Awaiting care package in own home Awaiting care package in own home

F2 Awaiting community equipment, telecare and/or Awaiting community equipment, telecare adaptations and/or adaptations

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 91 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

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

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

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

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

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

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

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

G9 Patient or Family choice - Supported Patient or Family choice - Supported accommodation accommodation

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

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

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

H1 Disputes Disputes

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

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

J2 Housing - Awaiting supported accommodation Housing - Awaiting supported accommodation

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

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 92 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Configured List Option

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

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

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

M504040 Mental Health Delayed Discharge Attributable to Indication Code An indication to which organisation the mental health delayed discharge period is attributable to. This is captured in Service Responsibility field of the Add Discharge Delay dialog.

National Code Extract Description SystmOne Options

04 NHS, excluding housing NHS

05 Social Care, excluding housing Social Care

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

07 Housing (including supported/specialist housing) Housing

MHS505 Restrictive Intervention

M505915 Ward Stay Identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M505040 Start Date (Restrictive Intevention) The start date of a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505020 Start Time (Restrictive Intervention) The start time of a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505020 Restrictive Intervention Type This is the type of restrictive intervention used. This is specified when recording a restrictive intervention from the Restrictive Interventions node in the patient record. SystmOne will automatically output the corresponding national codes below in the extract.

National Code Extract Description SystmOne Option

01 Physical restraint - Prone Physical restraint - Prone

07 Physical restraint – Standing Physical restraint – Standing

08 Physical restraint – Restrictive Escort Physical restraint – Restrictive Escort

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 93 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Option

09 Physical restraint – Supine Physical restraint – Supine

10 Physical restraint – Side Physical restraint – Side

11 Physical restraint - Seated Physical restraint - Seated

12 Physical restraint – Kneeling Physical restraint – Kneeling

13 Physical restraint – Other (not listed) Physical restraint – Other (not listed)

14 Chemical restraint – Injection (Rapid Chemical restraint – Injection (Rapid Tranquilisation) Tranquilisation)

15 Chemical restraint – Injection (Non Rapid Chemical restraint – Injection (Non Tranquilisation) Rapid Tranquilisation)

16 Chemical restraint - Oral Chemical restraint - Oral

17 Chemical restraint – Other (not listed) Chemical restraint – Other (not listed)

04 Mechanical restraint Mechanical restraint

05 Seclusion Seclusion

06 Segregation Segregation

M505060 End Date (Restrictive Intervention) The end date of a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505070 End Time (Restrictive Intervention) The end time of a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505080 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. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505090 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. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505100 Restrictive Intervention Restraint Injury Indicator (Other Person) An indication of whether an injury was sustained to any other person during an incident of restraint during a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505110 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. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 94 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M505120 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. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

M505130 Restrictive Intervention Post-Incident Review Held Indicator (Care Personnel) An indication of whether a Restrictive Intervention Post-Incident Review for the patient was held within 24 hours of the incident of a Restrictive Intervention. This is recorded when adding or amending a restrictive intervention from the Restrictive Interventions node in the patient record.

MHS506 Assault

M506915 Ward Stay identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M506010 Date of assault on patient This is the date that an instance of assault on the patient by another patient occurred. This is captured by recording the Read code ‘Assault on patient (Y159e)’. The date extracted is the date the Read code was added to the record.

MHS507 Self Harm

M507915 Ward Stay identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M507010 Date of Self-harm This is the date that an incident of self-harm for the patient occurred. This recorded by adding the Read code ‘[X]Intentional self-harm (XE22c)’ to the patient record. The date the Read code was added to the record is output in the extract. MHS509 Home Leave

M509915 Ward Stay identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M509010 Start Date (Home Leave) This is the start date for a period of home leave. This is the date the inpatient has been departed from the ward on SystmOne when they have had patient leave recorded with a Leave Type of Home Leave. Patient Leave can be recorded by right clicking on the patient in Inpatient Overview and selecting Administrative > Add Patient Leave. Patients can also be departed by right clicking on the patient in the Patient Leave tab of the In-patient Overview and selecting Departed.

M509020 Start Time (Home Leave) This is the start time for a period of Home Leave. This is the time the inpatient has been departed from the ward on SystmOne when they have had patient leave recorded with a Leave Type of Home Leave. Patient Leave can be recorded by right clicking on the patient in Inpatient Overview and selecting Administrative > Add Patient Leave. Patients can also be departed by right clicking on the patient in the Patient Leave tab of the In-patient Overview and selecting Departed.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 95 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M509030 End Date (Home Leave) This is the end date for a period of Home Leave and is the date the patient has returned to the ward after a period of patient leave that has been recorded with a Leave Type of Home Leave. On SystmOne, patients can be returned by right clicking on the patient in the Patients Returning section of the Patient Leave tab in the In-Patient Overview and selecting Ended.

M509040 End Time (Home Leave) This is the end time for a period of Home Leave and is the date the patient has returned to the ward after a period of patient leave that has been recorded with a Leave Type of Home Leave. On SystmOne, patients can be returned by right clicking on the patient in the Patients Returning section of the Patient Leave tab in the In-Patient Overview and selecting Ended.

MHS510 Mental Health Leave of Absence

M510915 Ward Stay identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M510010 Start Date (Mental Health Leave of Absence) This is the start date for a period of Mental health leave of absence. This is the date the inpatient has been departed from the ward on SystmOne when they have had patient leave recorded with a Leave Type of Leave of Absence. Patient Leave can be recorded by right clicking on the patient in Inpatient Overview and selecting Administrative > Add Patient Leave. Patients can also be departed by right clicking on the patient in the Patient Leave tab of the In-patient Overview and selecting Departed.

M510020 Start Time (Mental Health Leave of Absence) This is the start time for a period of Mental health leave of absence. This is the date the inpatient has been departed from the ward on SystmOne when they have had patient leave recorded with a Leave Type of Leave of Absence. Patient Leave can be recorded by right clicking on the patient in In-patient Overview and selecting Administrative > Add Patient Leave. Patients can also be departed by right clicking on the patient in the Patient Leave tab of the In-patient Overview and selecting Departed.

M510030 End Date (Mental Health Leave of Absence) This is the end date for a period of Mental health leave of absence and is the date the patient has returned to the ward after a period of patient leave that has been recorded with a Leave Type of Leave of Absence. On SystmOne, patients can be returned by right clicking on the patient in the Patients Returning section of the Patient Leave tab in the In-Patient Overview and selecting Ended.

M510040 End Time (Mental Health Leave of Absence) This is the end date for a period of Mental health leave of absence and is the date the patient has returned to the ward after a period of patient leave that has been recorded with a Leave Type of Leave of Absence. On SystmOne, patients can be returned by right clicking on the patient in the Patients Returning section of the Patient Leave tab in the In-Patient Overview and selecting Ended.

M510050 Mental Health Leave of Absence End Reason This is the reason a Mental Health Leave of Absence ended. This is recorded in SystmOne when the patient has been marked as returned. Patients can be returned by right clicking on the patient in the Patients Returning section of the Patient Leave tab in the In-Patient Overview and selecting Ended.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 96 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

The end reason is then selected from the End Reason field on the End Leave dialog. All leave of absence for the patient can be viewed on the Patient Leave node of the patient record.

National Code Extract Description SystmOne Configured List Option

01 Patient returned on or before day specified Patient returned on or before day specified

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

03 Period of leave to be extended Period of leave to be extended

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

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

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

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

08 Patient Died Patient's death

96 Other Other

99 Not Known Not Known

M510060 Escorted Mental Health Leave of Absence Indicator An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted. This is recorded as a Leave type in the Patient Leave dialog.

National Code Extract Description SystmOne Configured List Option

Y Yes, escorted Leave of Absence (Escorted)

N No, unescorted Leave of Absence (Unescorted)

MHS511 Mental Health Absence Without Leave

M511915 Ward Stay identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M511010 Start Date (Mental Health Absence without Leave) This is the start date of a period of Mental Health absence without leave for a patient detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. This is recorded by right clicking on an admitted patient and selecting Clinical > Mark as AWOL and populating the Started field. All absence without leave for the patient can be viewed on the Patient Leave node of the patient record.

M511020 Start Time (Mental Health Absence without Leave) This is the start time of a period of Mental Health absence without leave for a patient detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. This is recorded by right clicking on an admitted patient and selecting Clinical > Mark as AWOL and populating the Started field. All absence without leave for the patient can be viewed on the Patient Leave node of the patient record.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 97 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M511030 End Date (Mental Health Absence without Leave) This is the end date of a period of Mental Health absence without leave for a patient detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. This is recorded in SystmOne by right clicking on the patient on the Patient Leave tab of the In-patient Overview and selecting Ended. All leave of absence for the patient can be viewed on the Patient Leave node of the patient record.

M511040 End Time (Mental Health Absence without Leave) This is the end time of a period of Mental Health absence without leave for a patient detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995. This is recorded in SystmOne by right clicking on the patient on the Patient Leave tab of the In-patient Overview and selecting Ended. All leave of absence for the patient can be viewed on the Patient Leave node of the patient record.

M511050 Mental Health Absence without Leave End Reason This is the reason the Mental Health absence without leave ended. This is recorded in SystmOne by right clicking on the patient on the Patient Leave tab of the In-patient Overview and selecting Ended. The end reason is then selected from the End Reason drop down. All leave of absence for the patient can be viewed on the Patient Leave node of the patient record.

National Code Extract Description SystmOne Configured List Option

01 Patient returned voluntarily Patient returned voluntarily

02 Patient is taken back into custody Patient is taken back into custody

03 Patient fails to return by the end of the relevant Patient fails to return by the end of the period for which they are liable to be detained or relevant period subject to guardianship

04 Patient discharged, care or treatment finished Patient discharged, care or treatment finished

05 Patient died Patient died

99 Not known Not known

MHS512 Hospital Spell Commissioner

M512920 Hospital Provider Spell number This is the unique identifier for each Hospital Provider Spell. This will be generated automatically by SystmOne.

M512922 Organisation Identifier (Code of Commissioner) This is the ID of the organisation responsible for the GP Practice where the patient is registered at the time of the hospital spell, e.g. the CCG. Where there is no registered GP Practice, SystmOne will generate a CCG code based on the patient’s address. Where there is no fixed address for the patient, SystmOne will use the Commissioning CCG ID of the team recorded for that hospital spell. Where there is no Commissioning CCG ID for the team on the hospital spell, the CCG for the Mental Health Trust will be used.

M512010 Start Date (Commissioner Assignment Period) This is the start date of the commissioner assignment period. This is automatically extracted as the date the patient was registered at their GP practice or, if there is no registered GP, the date the address was added to the record. SystmOne will create multiple rows each time that there is a change. If the patient has neither a registered GP or address, then SystmOne will extract the start date of the Hospital Provider Spell.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 98 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M512020 End Date (Commissioner Assignment Period) This is the end date of the commissioner assignment period. This is automatically extracted as the date the patient moved from the registered GP or the date the patient moved out of area. If the patient has neither a registered GP or address, then SystmOne will extract the discharge date for the patient’s Hospital Provider Spell.

MHS513 Substance Misuse

M513915 Ward Stay Identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M513010 Observation Date (Substance Misuse Evidence) This is the date that evidence of current substance misuse by a patient was observed by a care professional. This will be recorded using the CTV3 Read code Evidence of Substance Misuse Observed (Y183c).

MHS514 Trial Leave

M514915 Ward Stay Identifier This is the unique identifier for a Ward Stay. This will be generated automatically by SystmOne.

M514010 Start Date (Mental Health Trial Leave) The Start Date of a period of Mental Health Trial Leave for a patient. This is the departure date of a Patient Leave period where the Leave type is set as Trial Leave.

M514020 Start Time (Mental Health Trial Leave) The Start Time of a period of Mental Health Trial Leave for a patient. This is the departure time of a Patient Leave period where the Leave type is set as Trial Leave.

M514030 End Date (Mental Health Trial Leave) The End Date of a period of Mental Health Trial Leave for a patient. This is the return date of a Patient Leave period where the Leave type is set as Trial Leave.

M514040 End Time (Mental Health Trial Leave) The End Time of a period of Mental Health Trial Leave for a patient. This is the return time of a Patient Leave period where the Leave type is set as Trial Leave.

MHS601 Medical History (Previous Diagnosis)

M601901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M601913 Diagnosis Scheme in Use The code scheme basis of the diagnosis. SystmOne uses the ICD-10 coding scheme for the Previous Diagnosis (Coded Clinical Entry).

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 99 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Description

02 ICD-10

M601010 Previous Diagnosis (Coded Clinical Entry) All ICD-10 diagnosis ever recorded in the patient’s record. These will be extracted regardless of whether the ICD- 10 diagnosis has been completed, saved for later or authorised. The ICD-10 diagnosis is captured in SystmOne by recording the ICD-10 Diagnosis code from the Clinical Codings node in SystmOne.

M601916 Diagnosis Date Diagnosis Date is the date that the diagnosis was made. Within SystmOne, this is captured in the Diagnosis Date field from the Record ICD Codes dialog. To record an ICD-10 code, users can right click on the relevant coding item within the Clinical Codings node and select Amend Coding or Start Coding. This will launch the Clinical Coding dialog and users can then select the Add a new diagnosis code icon, which will launch the Record ICD Codes dialog. This date can be viewed by expanding the relevant coding item and viewing the Diagnosed On date. MHS603 Provisional Diagnosis

M603902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M603913 Diagnosis Scheme In Use The code scheme basis of the diagnosis. SystmOne uses the ICD-10 coding scheme for the Previous Diagnosis (Coded Clinical Entry).

National Code Description

02 ICD-10

M603010 Provisional Diagnosis (Coded Clinical Entry) This is the provisional diagnosis of the person, for the main condition treated or investigated during the relevant episode of healthcare. Within SystmOne, each referral has a relevant coding item in the Clinical Codings node of the patient record. When a referral is created for the patient, a new coding item appears under the heading Uncoded Referrals within the Clinical Codings node of the Clinical tree. To create a Provisional Diagnosis, the user will need to right click on the coding item entry under the Uncoded Referrals heading and Start Coding. Once the ICD10 diagnosis has been selected and appears in the Diagnosis section of the Clinical Coding dialog, users will need to right click on the diagnosis and select “Provisional”. This is then identified by a question mark icon in the flags column on the Clinical Coding dialog or the text “(Provisional)” next to the diagnosis in the record.

M603020 Provisional Diagnosis Date Diagnosis Date is the date that the provisional diagnosis was made, see above for how to record a Provisional diagnosis. Within SystmOne, this is captured in the Diagnosis Date field from the Record ICD Codes dialog. This date can be viewed by expanding the relevant coding item and viewing the Diagnosed On date. This is available within the Clinical Codings node of the patient record.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 100 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS604 Primary Diagnosis

M604902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M604913 Diagnosis Scheme In Use The code scheme basis of the diagnosis. SystmOne uses the ICD-10 coding scheme for the Previous Diagnosis (Coded Clinical Entry).

National Code Description

02 ICD-10

M604010 Primary Diagnosis (Coded Clinical Entry) This is the primary diagnosis of the patient, for the main condition treated or investigated during the relevant episode of care. Within SystmOne, each referral has a relevant coding item in the Clinical Codings node of the patient record. When a referral is created for the patient, a new coding item appears under the heading Uncoded Referrals within the Clinical Codings node of the Clinical tree. To create a Primary Diagnosis, the user will need to right click on the coding item entry under the Uncoded Referrals heading and Start Coding. When the ICD10 diagnosis is recorded via the Record ICD10 Codes dialog, the code that displays in bold at the top of the list is the Primary Diagnosis. The Primary Diagnosis is represented slightly differently depending on whether you are viewing coded entries, or actually carrying out the coding. To check what the Primary Diagnosis was set as retrospectively, the user can navigate to the Clinical Codings node in the Clinical Tree, expand the coded entry that will now appear under the heading of Referral Codings, and the ICD10 diagnosis code that appears at the top in this entry is the Primary Diagnosis.

M604916 Diagnosis Date Diagnosis Date is the date that the primary diagnosis was made, see above for how to record a Primary diagnosis. Within SystmOne, this is captured in the Diagnosis Date field from the Record ICD Codes dialog. This date can be viewed by expanding the relevant coding item and viewing the Diagnosed On date. This is available within the Clinical Codings node of the patient record. MHS605 Secondary Diagnosis

M605902 Service Request Identifier This is the unique identifier for a service request. This will be generated automatically by SystmOne upon recording a new referral.

M605913 Diagnosis Scheme In Use The code scheme basis of the diagnosis. SystmOne uses the ICD-10 coding scheme for the Previous Diagnosis (Coded Clinical Entry).

National Code Description

02 ICD-10

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 101 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M605010 Secondary Diagnosis (Coded Clinical Entry) This is any other diagnosis other than the primary diagnosis. Within SystmOne, each referral has a relevant coding item in the Clinical Codings node. When a referral is created for the patient, a new coding item appears under the heading Uncoded Referrals within the Clinical Codings node of the Clinical tree. To create a Secondary Diagnosis, the user will need to right click on the coding item entry under the Uncoded Referrals heading and Start Coding. When the ICD10 diagnosis is recorded via the Record ICD10 Codes dialog, the code that displays in bold at the top of the list is the Primary Diagnosis. Any additional codes after this are secondary diagnoses. The Secondary Diagnosis is represented slightly differently depending on whether you are viewing coded entries, or actually carrying out the coding. To check what the Secondary Diagnoses were set as retrospectively, the user can navigate to the Clinical Codings node in the Clinical Tree, expand the coded entry that will now appear under the heading of Referral Codings, and any ICD10 diagnosis code that appears after the Primary Diagnosis are Secondary Diagnoses.

M605916 Diagnosis Date Diagnosis Date is the date that the secondary diagnosis was made, see above for how to record a Secondary diagnosis. Within SystmOne, this is captured in the Diagnosis Date field from the Record ICD Codes dialog. This date can be viewed by expanding the relevant coding item and viewing the Diagnosed On date. This is available within the Clinical Codings node of the patient record. MHS606 Coded Scored Assessment (Referral) The definition of Coded Scored Assessment (Referral) as defined in the specification by NHS Digital is: To carry details of scored assessments that are issued and completed as part of a referral to a mental health service, but do not take place at a specific contact. Because this information will always be captured as a contact in SystmOne, this table will not be populated when extracting the MHSDS data set.

MHS607 Coded Scored Assessment (Care Activity)

M607904 Care Activity Identifier This is the unique identifier for a care activity. It will be automatically generated by SystmOne when an activity is recorded.

M607910 Coded Assessment Tool Type (SNOMED CT) This is the SNOMED CT concept ID which is used to identify an assessment. In SystmOne this will be captured using CTV3 Read codes. Note that this data will only output into the MHSDS data set extract if the scored assessment has been entered as part of a Care Activity contact (see MHS202 Care Activity for further details). Recording the following CTV3 Read codes will extract the relevant SNOMED – CT codes. Where there is no equivalent Read code, no SNOMED – CT code will be extracted.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

961031000000108 Brief Parental Self-Efficacy Scale score Brief Parental Self-Efficacy Scale score (Y1b6f)

960771000000103 Child Group Session Rating Scale score Child Group Session Rating Scale score (Y1b70)

960321000000103 Child Outcome Rating Scale total score Child Outcome Rating Scale total score (Y1b71)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 102 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

860591000000104 Children's global assessment scale score Children's global assessment scale (XaXlo)

958051000000104 Clinical Outcomes in Routine Evaluation - 10 clinical Clinical outcomes in routine score evaluation 10 item score (XaO4A)

961191000000108 Commission for Health Improvement Experience of No equivalent available Service Questionnaire - Parent or Carer score

860571000000103 Commission for Health Improvement experience of No equivalent available service questionnaire score

987191000000101 Current View Contextual Problems score - community Current View Contextual Problems score – community (Y1b72)

987201000000104 Current View Contextual Problems score - home Current View Contextual Problems score – home (Y1b73)

987211000000102 Current View Contextual Problems score - school, work or Current View Contextual training Problems score - school, work or training (Y1b74)

987221000000108 Current View Contextual Problems score - service Current View Contextual engagement Problems score - service engagement (Y1b75)

987231000000105 Current View Education,Employment,Training score - Current View attainment difficulties Education,Employment,Training score - attainment difficulties (Y1b76)

987241000000101 Current View Education,Employment,Training score - Current View attendance difficulties Education,Employment,Training score - attendance difficulties (Y1b77)

987251000000103 Current View Provisional Problem Description item 1 Current View Provisional score - anxious away from caregivers Problem Description item 1 score - anxious away from caregivers (Y1b78)

987261000000100 Current View Provisional Problem Description item 2 Current View Provisional score - anxious in social situations Problem Description item 2 score - anxious in social situations (Y1b79)

987271000000107 Current View Provisional Problem Description item 3 Current View Provisional score - anxious generally Problem Description item 3 score - anxious generally (Y1b7a)

987281000000109 Current View Provisional Problem Description item 4 Current View Provisional score - compelled to do or think things Problem Description item 4 score - compelled to do or think things (Y1b7b)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 103 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

987291000000106 Current View Provisional Problem Description item 5 Current View Provisional score - panics Problem Description item 5 score – panics (Y1b7c)

987301000000105 Current View Provisional Problem Description item 6 Current View Provisional score - avoids going out Problem Description item 6 score - avoids going out (Y1b7d)

987311000000107 Current View Provisional Problem Description item 7 Current View Provisional score - avoids specific things Problem Description item 7 score - avoids specific things (Y1b7e)

987321000000101 Current View Provisional Problem Description item 8 Current View Provisional score - repetitive problematic behaviours Problem Description item 8 score - repetitive problematic behaviours (Y1b7f)

987331000000104 Current View Provisional Problem Description item 9 Current View Provisional score - depression/low mood Problem Description item 9 score - depression/low mood (Y1b80)

987341000000108 Current View Provisional Problem Description item 10 Current View Provisional score - self-harm Problem Description item 10 score - self-harm (Y1b81)

987351000000106 Current View Provisional Problem Description item 11 Current View Provisional score - extremes of mood Problem Description item 11 score - extremes of mood (Y1b82)

987361000000109 Current View Provisional Problem Description item 12 Current View Provisional score - delusional beliefs and hallucinations Problem Description item 12 score - delusional beliefs and hallucinations (Y1b83)

987371000000102 Current View Provisional Problem Description item 13 Current View Provisional score - drug and alcohol difficulties Problem Description item 13 score - drug and alcohol difficulties (Y1b84)

987381000000100 Current View Provisional Problem Description item 14 Current View Provisional score - difficulties sitting still or concentrating Problem Description item 14 score - difficulties sitting still or concentrating (Y1b85)

987391000000103 Current View Provisional Problem Description item 15 Current View Provisional score - behavioural difficulties Problem Description item 15 score - behavioural difficulties (Y1b86)

987401000000100 Current View Provisional Problem Description item 16 Current View Provisional score - poses risk to others Problem Description item 16 score - poses risk to others (Y1b87)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 104 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

987411000000103 Current View Provisional Problem Description item 17 Current View Provisional score - carer management of CYP (child or young person) Problem Description item 17 behaviour score - carer management of CYP (child or young person) behaviour (Y1b88)

987421000000109 Current View Provisional Problem Description item 18 Current View Provisional score - doesn' get to toilet in time Problem Description item 18 score - doesnt get to toilet in time (Y1b89)

987431000000106 Current View Provisional Problem Description item 19 Current View Provisional score - disturbed by traumatic event Problem Description item 19 score - disturbed by traumatic event (Y1b8a)

987441000000102 Current View Provisional Problem Description item 20 Current View Provisional score - eating issues Problem Description item 20 score - eating issues (Y1b8b)

987451000000104 Current View Provisional Problem Description item 21 Current View Provisional score - family relationship difficulties Problem Description item 21 score - family relationship difficulties (Y1b8c)

987461000000101 Current View Provisional Problem Description item 22 Current View Provisional score - problems in attachment to parent or carer Problem Description item 22 score - problems in attachment to parent or carer (Y1b8d)

987471000000108 Current View Provisional Problem Description item 23 Current View Provisional score - peer relationship difficulties Problem Description item 23 score - peer relationship difficulties (Y1b8e)

987481000000105 Current View Provisional Problem Description item 24 Current View Provisional score - persistent difficulties managing relationships with Problem Description item 24 others score - persistent difficulties managing relationships with others (Y1b8f)

987491000000107 Current View Provisional Problem Description item 25 Current View Provisional score - does not speak Problem Description item 25 score - does not speak (Y1b90)

987501000000101 Current View Provisional Problem Description item 26 Current View Provisional score - gender discomfort issues Problem Description item 26 score - gender discomfort issues (Y1b91)

987511000000104 Current View Provisional Problem Description item 27 Current View Provisional score - unexplained physical symptoms Problem Description item 27 score - unexplained physical symptoms (Y1b92)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 105 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

987521000000105 Current View Provisional Problem Description item 28 Current View Provisional score - unexplained developmental difficulties Problem Description item 28 score - unexplained developmental difficulties (Y1b93)

987531000000107 Current View Provisional Problem Description item 29 Current View Provisional score - self-care issues Problem Description item 29 score - self-care issues (Y1b94)

987541000000103 Current View Provisional Problem Description item 30 Current View Provisional score - adjustment to health issues Problem Description item 30 score - adjustment to health issues (Y1b95)

473345001 Eating disorder examination questionnaire eating concern EDE-Q (eat disord exam subscale score question) eating concern subscale (XaX4K)

446826001 Eating disorder examination questionnaire global score Eating disorder examination questionnaire global score (Y1b96)

473348004 Eating disorder examination questionnaire restraint EDE-Q (eating dsorder exam subscale score question) restraint subscale (XaX4J)

446039003 Eating disorder examination questionnaire score Eating disorder examination questionnaire (XaWRh)

473346000 Eating disorder examination questionnaire shape concern EDE-Q (eatin disord exam subscale score question) shape concern subscale (XaX4L)

473347009 Eating disorder examination questionnaire weight concern EDE-Q (eat disord exam subscale score question) weight concern subscale (XaX4M)

445455005 Generalized anxiety disorder 7 item score Generalised anxiety disorder 7 item score (XaNkT)

959951000000108 Goal Progress Chart - Child/Young Person - goal score No equivalent available

960711000000108 Group Session Rating Scale score Group Session Rating Scale score (Y1b98)

979641000000103 HoNOS (Health of the Nation Outcome Scales) for Health of Nat Outc Sc item 1 - working age adults rating scale 1 score - overactive, aggressive/disrupt behaviour aggressive, disruptive or agitated behaviour (Xa1e1)

979651000000100 HoNOS (Health of the Nation Outcome Scales) for Health of Nat Outc Scale item 2 working age adults rating scale 2 score - non-accidental - non-accidental self injury self-injury (Xa1e3)

979661000000102 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcome working age adults rating scale 3 score - problem drinking Scale item 3 - alcoh/drug probl or drug-taking (Xa1e4)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 106 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

979671000000109 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcome working age adults rating scale 4 score - cognitive Scale item 4 - cognitive probl problems (Xa1e5)

979681000000106 HoNOS (Health of the Nation Outcome Scales) for Health of Nation Outcome working age adults rating scale 5 score - physical illness Scale item 5 - phys illn/disabil or disability problems (Xa1e7)

979691000000108 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcome working age adults rating scale 6 score - problems Scale item 6 - associated with hallucinations and delusions hallucinat/delus (Xa1e8)

979701000000108 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcome working age adults rating scale 7 score - problems with Scale item 7 - depressed mood depressed mood (Xa1e9)

979711000000105 HoNOS (Health of the Nation Outcome Scales) for Health of Nat Outcome Scale working age adults rating scale 8 score - other mental and item 8 - other ment/behav probl behavioural problems (Xa1eA)

979831000000108 HoNOS (Health of the Nation Outcome Scales) for HoNOS Rating 8 Type - working age adults rating scale 8 type - other mental and Phobic (Y11e1) behavioural problems HoNOS Rating 8 Type - Anxiety (Y11e2) HoNOS Rating 8 Type - Obsessive-compulsive (Y11e3) HoNOS Rating 8 Type - Stress (Y11e4) HoNOS Rating 8 Type - Dissociative (Y11e5) HoNOS Rating 8 Type - Somatoform (Y11e6) HoNOS Rating 8 Type - Eating (Y11e7) HoNOS Rating 8 Type - Sleep (Y11e8) HoNOS Rating 8 Type - Sexual (Y11e9) HoNOS Rating 8 Type - Other (Y11ea)

979721000000104 HoNOS (Health of the Nation Outcome Scales) for Health of Nation Outcome working age adults rating scale 9 score - problems with Scale item 9 - relationship probl relationships (Xa1eB)

979731000000102 HoNOS (Health of the Nation Outcome Scales) for Health of Nation Outcome working age adults rating scale 10 score - problems with Scale item 10 - activit daily liv activities of daily living (Xa1eC)

979741000000106 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcome working age adults rating scale 11 score - problems with scale item 11 - living condit living conditions (Xa1eD)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 107 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

979751000000109 HoNOS (Health of the Nation Outcome Scales) for Health of the Nation Outcomes working age adults rating scale 12 score - problems with scale item 12 - occup/activit occupation and activities (Xa1eE)

980761000000107 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 1 - rating scale 1 score - behavioural disturbance Behavioural disturbance (Y124b)

980771000000100 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 2 - Non- rating scale 2 score - non-accidental self-injury accidental self injury (Y124c)

980781000000103 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 3 - rating scale 3 score - problem-drinking or drug-use Problem drinking or drug use (Y124d)

980791000000101 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 4 - rating scale 4 score - cognitive problems Cognitive problems (Y124e)

980801000000102 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 5 - rating scale 5 score - problems related to physical Problems related to Physical illness/disability Illness/disability (Y124f)

980811000000100 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS 65+ (Health of the rating scale 6 score - problems associated with Nation Outcome Scales 65+) hallucinations and/or delusions (or false beliefs) rating scale 6 score - problems associated with hallucinations and/or delusions (or false beliefs)

980821000000106 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 7 - rating scale 7 score - problems with depressive symptoms Problems with depressive symptoms (Y125b)

980831000000108 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 8 - Other rating scale 8 score - other mental and behavioural mental and behavioural problems problems (Y125c)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 108 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

985981000000108 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus Rating 8 rating scale 8 type - other mental and behavioural Type - Phobic (Y126b) problems HoNOS65-Plus Rating 8 Type - Anxiety (Y126c) HoNOS65-Plus Rating 8 Type - Obsessive- compulsive (Y126d) HoNOS65-Plus Rating 8 Type - Mental strain/tension (Y126e) HoNOS65-Plus Rating 8 Type - Dissociative (Y126f) HoNOS65-Plus Rating 8 Type - Somatoform (Y127a) HoNOS65-Plus Rating 8 Type - Eating (Y127b) HoNOS65-Plus Rating 8 Type - Sleep (Y127c) HoNOS65-Plus Rating 8 Type - Sexual (Y127d) HoNOS65-Plus Rating 8 Type - Other (Y127e)

980841000000104 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 9 - rating scale 9 score - problems with social or supportive Problems with relationships relationships (Y125d)

980851000000101 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 10 - rating scale 10 score - problems with activities of daily Problems with activities of living daily living (Y125e)

980861000000103 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 11 - rating scale 11 score - overall problems with living Overall problems with living conditions conditions (Y125f)

980871000000105 HoNOS 65+ (Health of the Nation Outcome Scales 65+) HoNOS65-Plus item 12 - rating scale 12 score - problems with work and leisure Problems with activities activities - quality of daytime environment (Y126a)

963521000000103 HoNOSCA (Health of the Nation Outcome Scale for Health of the Nation Outcome Children and Adolescents) - Parent's assessment score Scale for children and adolesc (XaJMN)

989881000000104 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 1 - disruptive Children and Adolescents) - parent's assessment scale 1 antisocial aggressive behaviour score - disruptive, antisocial or aggressive behaviour (XaarB)

989931000000107 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 2 - overactivity, Children and Adolescents) - parent's assessment scale 2 attention and concentration score - overactivity, attention and concentration (XaarC)

989941000000103 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 3 - non- Children and Adolescents) - parent's assessment scale 3 accidental self injury (XaarD) score - non-accidental self injury

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 109 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

989941000000103 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 3 - non- Children and Adolescents) - parent's assessment scale 3 accidental self injury score - non-accidental self injury (XaarD)

989951000000100 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 4 - alcohol, Children and Adolescents) - parent's assessment scale 4 substance/solvent misuse score - alcohol, substance/solvent misuse (XaarE)

989961000000102 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 5 - scholastic Children and Adolescents) - parent's assessment scale 5 or language skills (XaarF) score - scholastic or language skills

989971000000109 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 6 - physical Children and Adolescents) - parent's assessment scale 6 illness or disability problems score - physical illness or disability problems (XaarG)

989981000000106 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 7 - Children and Adolescents) - parent's assessment scale 7 hallucinations and delusions score - hallucinations and delusions (XaarH)

989991000000108 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 8 - non-organic Children and Adolescents) - parent's assessment scale 8 somatic symptoms (XaarI) score - non-organic somatic symptoms

990001000000107 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 9 - emotional Children and Adolescents) - parent's assessment scale 9 and related symptoms (XaarJ) score - emotional and related symptoms

989891000000102 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 10 - peer Children and Adolescents) - parent's assessment scale 10 relationships (XaarK) score - peer relationships

989901000000101 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 11 - self care Children and Adolescents) - parent's assessment scale 11 and independence (XaarL) score - self care and independence

989911000000104 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 12 - family life Children and Adolescents) - parent's assessment scale 12 and relationships (XaarM) score - family life and relationships

989921000000105 HoNOSCA (Health of the Nation Outcome Scales for HoNOSCA item 13 - poor Children and Adolescents) - parent's assessment scale 13 school attendance (XaarN) score - poor school attendance

989751000000102 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 1 score - disruptive, antisocial or aggressive behaviour

989801000000109 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 2 score - overactivity, attention and concentration

989811000000106 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 3 score - non-accidental self injury

989821000000100 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 4 score - alcohol, substance/solvent misuse

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 110 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

989831000000103 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 5 score - scholastic or language skills

989841000000107 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 6 score - physical illness or disability problems

989851000000105 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 7 score - hallucinations and delusions

989861000000108 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 8 score - non-organic somatic symptoms

989871000000101 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 9 score - emotional and related symptoms

989761000000104 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 10 score - peer relationships

989771000000106 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 11 score - self care and independence

989781000000108 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 12 score - family life and relationships

989791000000105 HoNOSCA-CR (Health of the Nation Outcome Scales for No equivalent available Children and Adolescents - clinician-rated) scale 13 score - poor school attendance

989621000000101 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 1 score - Nation Outcome Scales for disruptive, antisocial or aggressive behaviour Children and Adolescents - self- rated) scale 1 score - disruptive, antisocial or aggressive behaviour (Y1ba6)

989671000000102 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 2 score - Nation Outcome Scales for overactivity, attention and concentration Children and Adolescents - self- rated) scale 2 score - overactivity, attention and concentration (Y1bab)

989681000000100 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 3 score - Nation Outcome Scales for non-accidental self injury Children and Adolescents - self- rated) scale 3 score - non- accidental self injury (Y1bac)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 111 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

989691000000103 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 4 score - Nation Outcome Scales for alcohol, substance/solvent misuse Children and Adolescents - self- rated) scale 4 score - alcohol, substance/solvent misuse (Y1bad)

989701000000103 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 5 score - Nation Outcome Scales for scholastic or language skills Children and Adolescents - self- rated) scale 5 score - scholastic or language skills (Y1bae)

989711000000101 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 6 score - Nation Outcome Scales for physical illness or disability problems Children and Adolescents - self- rated) scale 6 score - physical illness or disability problems (Y1baf)

989721000000107 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 7 score - Nation Outcome Scales for hallucinations and delusions Children and Adolescents - self- rated) scale 7 score - hallucinations and delusions (Y1bb0)

989731000000109 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 8 score - Nation Outcome Scales for non-organic somatic symptoms Children and Adolescents - self- rated) scale 8 score - non- organic somatic symptoms (Y1bb1)

989741000000100 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 9 score - Nation Outcome Scales for emotional and related symptoms Children and Adolescents - self- rated) scale 9 score - emotional and related symptoms (Y1bb2)

989631000000104 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 10 score - Nation Outcome Scales for peer relationships Children and Adolescents - self- rated) scale 10 score - peer relationships (Y1ba7)

989641000000108 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 11 score - Nation Outcome Scales for self care and independence Children and Adolescents - self- rated) scale 11 score - self care and independence (Y1ba8)

989651000000106 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 12 score - Nation Outcome Scales for family life and relationships Children and Adolescents - self- rated) scale 12 score - family life and relationships (Y1ba9)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 112 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

989661000000109 HoNOSCA-SR (Health of the Nation Outcome Scales for HoNOSCA-SR (Health of the Children and Adolescents - self-rated) scale 13 score - Nation Outcome Scales for poor school attendance Children and Adolescents - self- rated) scale 13 score - poor school attendance (Y1baa)

987711000000106 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 1 Score - People with Learning Disabilities) rating scale 1 score - behavioural problems (directed behavioural problems (directed at others) at others) (Y133a)

987811000000101 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 2 Score - People with Learning Disabilities) rating scale 2 score - behavioural problems (directed behavioural problems directed towards self (self-injury) towards self) (Y133b)

988261000000101 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 3A Score - People with Learning Disabilities) rating scale 3A score - behaviour destructive to behaviour destructive to property property (Y133c)

988271000000108 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 3B Score - People with Learning Disabilities) rating scale 3B score - problems with personal problems with personal behaviours behaviours (Y133d)

988281000000105 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 3C Score - People with Learning Disabilities) rating scale 3C score - rocking, stereotyped and rocking, stereotyped and ritualistic behaviour ritualistic behaviour (Y133e)

988291000000107 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 3D Score - People with Learning Disabilities) rating scale 3D score - anxiety, phobias, obsessive, anxiety, phobias, obsessive or compulsive behaviour compulsive behaviour (Y133f)

988301000000106 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 3E Score - People with Learning Disabilities) rating scale 3E score - other behaviours (Y134a) others

987831000000109 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 4 Score - People with Learning Disabilities) rating scale 4 score - attention and concentration attention and concentration (Y134b)

987841000000100 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 5 Score - People with Learning Disabilities) rating scale 5 score - memory and orientation memory and orientation (Y134c)

987851000000102 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 6 Score - People with Learning Disabilities) rating scale 6 score - communication (problems with communication (problems with understanding) understanding) (Y134d)

987861000000104 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 7 Score - People with Learning Disabilities) rating scale 7 score - communication (problems with communication (problems with expression) expression) (Y134e)

987871000000106 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 8 Score - People with Learning Disabilities) rating scale 8 score - problems associated with problems associated with hallucinations and delusions hallucinations and delusions (Y134f)

987881000000108 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 9 Score - People with Learning Disabilities) rating scale 9 score - problems associated with mood problems associated with mood changes changes (Y135a)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 113 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

987721000000100 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 10 Score - People with Learning Disabilities) rating scale 10 score - problems with sleeping (Y135b) problems with sleeping

987731000000103 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 11 Score - People with Learning Disabilities) rating scale 11 score - problems with eating and problems with eating and drinking drinking (Y135c)

987741000000107 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 12 Score - People with Learning Disabilities) rating scale 12 score - physical problems (Y135d) physical problems

987751000000105 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 13 Score - People with Learning Disabilities) rating scale 13 score - seizures (Y135e) seizures

987761000000108 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 14 Score - People with Learning Disabilities) rating scale 14 score - activities of daily living at home activities of daily living at home (Y135f)

987771000000101 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 14 Score - People with Learning Disabilities) rating scale 15 score - activities of daily living at home activities of daily living outside the home (Y135f)

987781000000104 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 16 Score - People with Learning Disabilities) rating scale 16 score - level of self care (Y136b) level of self-care

987791000000102 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 17 Score - People with Learning Disabilities) rating scale 17 score - problems with relationships problems with relationships (Y136c)

987801000000103 HoNOS-LD (Health of the Nation Outcome Scales for HoNOS LD Rating 18 Score - People with Learning Disabilities) rating scale 18 score - occupation and activities occupation and activities (Y136d)

981391000000108 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating scale A secure) rating scale A score - risk of harm to adults or - potential harm to others children (XaJMS)

981401000000106 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating scale B secure) rating scale B score - risk of self-harm (deliberate -potential self harm or neglect or accidental) (XaJMT)

981411000000108 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating C - secure) rating scale C score - need for buildings security need for build secur to prev to prevent escape escape (XaJMU)

981421000000102 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating D - secure) rating scale D score - need for safely staffed living need for safely staffed living environment env (XaJMV)

981431000000100 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating scale E secure) rating scale E score - need for escort on leave - need for escort on leave (beyond secure perimeter) (XaJMW)

981441000000109 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating F - secure) rating scale F score - risk to individual from others poten harm to individ frm others (XaJMX)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 114 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

981451000000107 HoNOS-secure (Health of the Nation Outcome Scales- HoNOS-secure: Rating G - secure) rating scale G score - need for risk management need for specialist clin procedures procedures (XaJMY)

961231000000104 How Are Things? Behavioural Difficulties (Oppositional No equivalent available Defiant Disorder) - Parent/Carer score

963561000000106 Kessler Psychological Distress Scale 10 score No equivalent available

960221000000105 MAMS (Me and My School) Questionnaire behavioural No equivalent available difficulties score

960211000000104 MAMS (Me and My School) Questionnaire score No equivalent available

985071000000105 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating 13 score

985081000000107 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating A score

985111000000104 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating B score

985121000000105 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating C score

985131000000107 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating D score

985141000000103 Mental Health Clustering Tool Summary Assessments of No equivalent available Risk and Need rating E score

960251000000100 Outcome Rating Scale total score No equivalent available

506701000000100 Patient health questionnaire 9 score Patient health questionnaire (PHQ-9) score (XaLDN)

958231000000102 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Depression score

958251000000109 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Generalized Anxiety score

958261000000107 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Obsessions/Compulsions score

958221000000104 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Panic score

958241000000106 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Separation Anxiety score

958211000000105 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Social Phobia score

958281000000103 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Total Anxiety and Depression score

958271000000100 RCADS (Revised Children's Anxiety and Depression No equivalent available Scale) - Total Anxiety score

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 115 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

960181000000100 Revised Child Impact of Events Scale score No equivalent available

960021000000100 SCORE Index of Family Function and Change - 15 - No equivalent available average total score

960131000000104 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 1 - Strengths and Adaptability average score

959981000000102 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 1 - Strengths and Adaptability total score

960141000000108 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 2 - Overwhelmed by Difficulties average score

959991000000100 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 2 - Overwhelmed by Difficulties total score

960151000000106 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 3 - Disrupted Communication average score

960001000000109 SCORE Index of Family Function and Change - 15 - No equivalent available Dimension 3 - Disrupted Communication total score

959961000000106 SCORE Index of Family Function and Change - 15 - total No equivalent available score

986241000000103 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - conduct problems - educator score

986311000000109 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - conduct problems - parent score

986251000000100 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - emotional symptoms - educator score

986321000000103 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - emotional symptoms - parent score

986261000000102 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - hyperactivity - educator score

986331000000101 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - hyperactivity - parent score

986271000000109 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - impact - educator score

986341000000105 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - impact - parent score

986281000000106 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - peer problems - educator score

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 116 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

986351000000108 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - peer problems - parent score

986291000000108 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - prosocial - educator score

986361000000106 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - prosocial - parent score

986301000000107 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - total difficulties - educator score

986371000000104 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds - total difficulties - parent score

963571000000104 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 2-4 year olds score

986061000000108 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - conduct problems - parent score

986151000000106 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - conduct problems - teacher score

986071000000101 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - emotional symptoms - parent score

986161000000109 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - emotional symptoms - teacher score

986081000000104 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - hyperactivity - parent score

986171000000102 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - hyperactivity - teacher score

986091000000102 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - impact - parent score

986181000000100 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - impact - teacher score

986101000000105 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - peer problems - parent score

986111000000107 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - prosocial - parent score

986201000000101 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - prosocial - teacher score

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 117 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) SystmOne Read code

986121000000101 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - total difficulties - parent score

986211000000104 SDQ (Strengths and Difficulties Questionnaire) for parents No equivalent available or educators of 4-17 year olds - total difficulties - teacher score

985991000000105 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - conduct problems score

986001000000109 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - emotional symptoms score

986011000000106 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - hyperactivity score

986051000000105 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - impact score

986021000000100 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - peer problems score

986031000000103 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - prosocial score

986041000000107 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds - total difficulties score

963591000000100 SDQ (Strengths and Difficulties Questionnaire) self-rated No equivalent available for 11-17 year olds score

961351000000103 Session Feedback Questionnaire score No equivalent available

960451000000101 Session Rating Scale score No equivalent available

860641000000108 Sheffield learning disabilities outcome measure score Sheffield learning disabilities outcome measure (XaZqU)

960481000000107 Short Warwick-Edinburgh Mental Well-being Scale score No equivalent available

986191000000103 Strengths and Difficulties Questionnaire for parents or No equivalent available educators of 4-17 year olds - peer problems - teacher score

963581000000102 Strengths and Difficulties Questionnaire for parents or No equivalent available teachers of 4-17 year olds score

885541000000103 Warwick-Edinburgh Mental Well-being Scale score Warwick-Edinburgh Mental Well-being Scale (Xaacs)

960391000000100 Young Child Outcome Rating Scale score No equivalent available

960601000000104 Young Person's Clinical Outcomes in Routine Evaluation No equivalent available clinical score

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 118 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M607911 Person Score This is the score resulting from a coded assessment. SystmOne will automatically extract this numeric from the Coded Assessment Scored CTV3 Read codes that have been added to the patient record (associated with the Care Activity).

MHS608 Anonymous Self-Assessment SystmOne does not facilitate for the capture of anonymous self-assessment as all data items are associated with a patient record; therefore, this table will not be populated when extracting the MHSDS data set. MHS701 Care Programme Approach (CPA) Care Episode

M701918 Care Programme Approach Care Episode Identifier This is the unique identifier allocated to each Care Programme Approach Care Episode. This will be generated automatically by SystmOne.

M701901 Local Patient Identifier (Extended) This is a system-generated number used to identify a patient uniquely within a Health Care Provider. It will be assigned automatically by SystmOne.

M701010 Start Date (Care Programme Approach Care) This is the start date for the patient’s Care Programme Approach Care. On the CPA node within SystmOne, users can add or amend existing CPAs. From this screen, users can set a start date

M701020 End Date (Care Programme Approach Care) This is the end date for the patient’s Care Programme Approach Care. On the CPA node within SystmOne, users can add or amend existing CPAs. From this screen, users can set an end date.

MHS702 Care Programme Approach Review

M702918 Care Programme Approach Care Episode Identifier This is a unique identifier allocated to each Care Programme Approach Care Episode. This will be generated automatically by SystmOne.

M702010 Care Programme Approach Review Date This is the date of the Care Programme Approach Review. This can be recorded in the CPA Review dialog, when completing the Care Programme Approach Review for an existing Care Programme Approach in the CPA node.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 119 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M702020 Care Programme Approach Review Abuse Question Asked Indicator This is an indication of whether the patient was asked the Abuse Question during a Care Programme Approach Review. This can be recorded in the CPA Review dialog, when completing the Care Programme Approach Review for an existing Care Programme Approach in the CPA node. This indicator should not be used to record the answer to the Abuse Question itself.

National Code Extract Description SystmOne Configured List Option

Y Yes, the patient was asked Yes

N No, the patient was not asked No

9 Not known Not known

M702908 Care Professional Local Identifier This is a system-generated unique local care professional identifier within a Health Care Provider assigned automatically by SystmOne.

MHS801 Clustering Tool

M801919 Clustering Tool Assessment Identifier This is the unique identifier for each Clustering Tool Assessment. This will be generated automatically by SystmOne.

M801901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. This will be generated automatically by SystmOne.

M801010 Clustering Tool Assessment Category The category of the clustering tool assessment completed. This is worked out by mapping the Read codes used in a questionnaire.

National Code Extract Description SystmOne Read code mapping

01 Adult Mental Health Clustering Tool Health of the Nation Outcome Scale (generic version) (XM0e9) and children

03 Learning Disabilities Clustering Tool Not mapped, see below

04 Forensic (Mental Health) Clustering Tool Health of the Nation Outcome Scale for secure services (XaJMO) and children

05 Forensic (Learning Disabilities) Clustering Tool Not mapped, see below

06 Child and Adolescent Mental Health Needs Not mapped, NHS Digital have confirmed Based Grouping Tool that this is only applicable to trusts in the Needs Based Grouping pilot.

Please note that only ’01 - Adult Mental Health’ and ’04 - Forensic (Mental Health) Clustering Tool’ are mapped and valid until further categories become in scope for the MHSDS, as specified in the NHS Digital MHSDS User Guidance V2.0.2.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 120 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M801020 Assessment Tool Completion Date The date on which a clustering tool assessment was completed for a patient. Within SystmOne, a questionnaire created with the tick box of ‘MHCT’ questionnaire ticked is an MHCT questionnaire. The Assessment Tool Completion Date is the date that an MHCT Questionnaire was saved as a final version.

M801030 Assessment Tool Completion Time The time on which a clustering tool assessment was completed for a patient. Within SystmOne, a questionnaire created with the tick box of ‘MHCT’ questionnaire ticked is an MHCT questionnaire. The Assessment Tool Completion Time is the time that an MHCT Questionnaire was saved as a final version.

M801040 Clustering Tool Assessment Reason The reason that the clustering tool assessment for the patient was undertaken. A question should be added into the Assessment to capture the following codes, so that the relevant National Code is pulled into the extract:

National Code Extract Description SystmOne Read code

10 Initial Assessment Mental Health Clustering Tool Assessment Reason - Initial Assessment (Y120f)

11 Scheduled Re-Assessment Mental Health Clustering Tool Assessment Reason - Scheduled Re- Assessment (Y121a)

12 Re-Assessment following significant Mental Health Clustering Tool unanticipated change in need Assessment Reason - Re-assessment following significant unanticipated change in need (Y121b)

97 Other not elsewhere specified Mental Health Clustering Tool Assessment Reason - Other not elsewhere specified (Y120a)

99 Not known Mental Health Clustering Tool Assessment Reason - Not known (Y120b)

M801060 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. In SystmOne this is recorded after completing a MHCT assessment in the New Cluster dialog.

M801050 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. This applies to a Clustering Tool Assessment with the category of Adult Mental Health. In SystmOne the cluster code is recorded after completing a MHCT assessment in the New Cluster dialog, when the Initial Cluster tick box is ticked.

M801080 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, without reference to the National Tariff Payment System clustering algorithm. This applies to a Clustering Tool Assessment with the category of Learning Disabilities. Please note that this data item is not currently in use, as specified in the NHS Digital MHSDS User Guidance V3.0.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 121 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M801100 Forensic Learning Disabilities Care Cluster Code (Initial) Forensic care cluster code (initial) is the initial allocation of the forensic care cluster code by the care professional, without reference to the National Tariff Payment System clustering algorithm. This applies to a Clustering Tool Assessment with the category of Forensic (Learning Disabilities). Please note that this data item is not currently in use, as specified in the NHS Digital MHSDS User Guidance V3.0. MHS802 Clustering Assessment

M802919 Clustering Tool Assessment Identifier A unique identifier for each clustering tool assessment that takes place for each patient. This will be generated automatically by SystmOne.

M802910 Coded Assessment Tool Type This is the SNOMED CT concept ID for the clustering tool assessment used. In SystmOne this will be captured using CTV3 Read codes. Recording the following CTV3 Read codes in a MHCT Questionnaire will extract the relevant SNOMED–CT codes.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

860591000000104 Children's global assessment scale score Children's global assessment scale (XaXlo)

958051000000104 Clinical Outcomes in Routine Evaluation - 10 Clinical outcomes in routine evaluation clinical score 10 item score (XaO4A)

473345001 Eating disorder examination questionnaire EDE-Q (eat disord exam question) eating concern subscale score eating concern subscale (XaX4K)

473348004 Eating disorder examination questionnaire EDE-Q (eating dsorder exam question) restraint subscale score restraint subscale (XaX4J)

446039003 Eating disorder examination questionnaire Eating disorder examination score questionnaire (XaWRh)

473346000 Eating disorder examination questionnaire EDE-Q (eatin disord exam question) shape concern subscale score shape concern subscale (XaX4L)

473347009 Eating disorder examination questionnaire EDE-Q (eat disord exam question) weight concern subscale score weight concern subscale (XaX4M)

1060801000000108 Forensic Mental Health Clustering Tool HoNOS Forensic item 13 - Strong Summary Assessments of Risk and Need rating unreasonable beliefs that are not 13 score (observable entity) psychotic in origin (Y18de)

1053271000000103 Forensic Mental Health Clustering Tool HoNOS Forensic item 40 - Need for Summary Assessments of Risk and Need rating physical security to provide safe 40 score (observable entity) treatment for the patient (Y18df)

1060811000000105 Forensic Mental Health Clustering Tool HoNOS Forensic item A - Agitated Summary Assessments of Risk and Need rating behaviour/expansive mood (Y18e0) A score (observable entity)

1060821000000104 Forensic Mental Health Clustering Tool HoNOS Forensic item B - Repeat self- Summary Assessments of Risk and Need rating harm (Y18e1) B score (observable entity)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 122 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

1060831000000102 Forensic Mental Health Clustering Tool HoNOS Forensic item C - Safeguarding Summary Assessments of Risk and Need rating other children & vulnerable adults C score (observable entity) (Y18e2)

1060841000000106 Forensic Mental Health Clustering Tool HoNOS Forensic item D - Engagement Summary Assessments of Risk and Need rating (Y18e3) D score (observable entity)

1060851000000109 Forensic Mental Health Clustering Tool HoNOS Forensic item E - Vulnerability Summary Assessments of Risk and Need rating (Y18e4) E score (observable entity)

1053281000000101 Forensic Mental Health Clustering Tool HoNOS Forensic item P - Interpersonal Summary Assessments of Risk and Need rating Dynamics (Y18e5) P score (observable entity)

1053291000000104 Forensic Mental Health Clustering Tool HoNOS Forensic item Q - Problem- Summary Assessments of Risk and Need rating drinking or drug-taking (Y18e6) Q score (observable entity)

1053301000000100 Forensic Mental Health Clustering Tool HoNOS Forensic item - Antisocial Summary Assessments of Risk and Need rating attitudes likely to result in behaviour that R score (observable entity) causes a risk to others (Y18e7)

979641000000103 HoNOS (Health of the Nation Outcome Scales) Health of Nat Outc Sc item 1 - for working age adults rating scale 1 score - aggressive/disrupt behaviour (Xa1e1) overactive, aggressive, disruptive or agitated behaviour

979651000000100 HoNOS (Health of the Nation Outcome Scales) Health of Nat Outc Scale item 2 - non- for working age adults rating scale 2 score - accidental self injury (Xa1e3) non-accidental self-injury

979661000000102 HoNOS (Health of the Nation Outcome Scales) Health of the Nation Outcome Scale for working age adults rating scale 3 score - item 3 - alcoh/drug probl (Xa1e4) problem drinking or drug-taking

979671000000109 HoNOS (Health of the Nation Outcome Scales) Health of the Nation Outcome Scale for working age adults rating scale 4 score - item 4 - cognitive probl (Xa1e5) cognitive problems

979681000000106 HoNOS (Health of the Nation Outcome Scales) Health of Nation Outcome Scale item 5 - for working age adults rating scale 5 score - phys illn/disabil (Xa1e7) physical illness or disability problems

979691000000108 HoNOS (Health of the Nation Outcome Scales) Health of the Nation Outcome Scale for working age adults rating scale 6 score - item 6 - hallucinat/delus (Xa1e8) problems associated with hallucinations and delusions

979701000000108 HoNOS for working age adults rating scale 7 Health of the Nation Outcome Scale score - problems with depressed mood item 7 - depressed mood (Xa1e9)

979711000000105 HoNOS (Health of the Nation Outcome Scales) Health of Nat Outcome Scale item 8 - for working age adults rating scale 8 score - other ment/behav probl (Xa1eA) other mental and behavioural problems

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 123 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

979831000000108 HoNOS (Health of the Nation Outcome Scales) HoNOS Rating 8 Type - Phobic (Y11e1) for working age adults rating scale 8 type - other HoNOS Rating 8 Type - Anxiety (Y11e2) mental and behavioural problems HoNOS Rating 8 Type - Obsessive- compulsive (Y11e3) HoNOS Rating 8 Type - Stress (Y11e4) HoNOS Rating 8 Type - Dissociative (Y11e5) HoNOS Rating 8 Type - Somatoform (Y11e6) HoNOS Rating 8 Type - Eating (Y11e7) HoNOS Rating 8 Type - Sleep (Y11e8) HoNOS Rating 8 Type - Sexual (Y11e9) HoNOS Rating 8 Type - Other (Y11ea)

979721000000104 HoNOS (Health of the Nation Outcome Scales) Health of Nation Outcome Scale item 9 - for working age adults rating scale 9 score - relationship probl (Xa1eB) problems with relationships

979731000000102 HoNOS (Health of the Nation Outcome Scales) Health of Nation Outcome Scale item 10 for working age adults rating scale 10 score - - activit daily liv (Xa1eC) problems with activities of daily living

979741000000106 HoNOS (Health of the Nation Outcome Scales) Health of the Nation Outcome scale item for working age adults rating scale 11 score - 11 - living condit (Xa1eD) problems with living conditions

979751000000109 HoNOS (Health of the Nation Outcome Scales) Health of the Nation Outcomes scale for working age adults rating scale 12 score - item 12 - occup/activit (Xa1eE) problems with occupation and activities

980761000000107 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 1 - Behavioural Scales 65+) rating scale 1 score - behavioural disturbance (Y124b) disturbance

980771000000100 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 2 - Non-accidental Scales 65+) rating scale 2 score - non- self injury (Y124c) accidental self-injury

980781000000103 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 3 - Problem Scales 65+) rating scale 3 score - problem- drinking or drug use (Y124d) drinking or drug-use

980791000000101 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 4 - Cognitive Scales 65+) rating scale 4 score - cognitive problems (Y124e) problems

980801000000102 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 5 - Problems Scales 65+) rating scale 5 score - problems related to Physical Illness/disability related to physical illness/disability (Y124f)

980811000000100 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 6 - Problems Scales 65+) rating scale 6 score - problems associated with hallucinations and/or associated with hallucinations and/or delusions delusions (or false beliefs) (Y125a) (or false beliefs)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 124 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

980821000000106 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 7 - Problems with Scales 65+) rating scale 7 score - problems with depressive symptoms (Y125b) depressive symptoms

980831000000108 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 8 - Other mental Scales 65+) rating scale 8 score - other mental and behavioural problems (Y125c) and behavioural problems

985981000000108 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus Rating 8 Type - Phobic Scales 65+) rating scale 8 type - other mental (Y126b) and behavioural problems HoNOS65-Plus Rating 8 Type - Anxiety (Y126c) HoNOS65-Plus Rating 8 Type - Obsessive-compulsive (Y126d) HoNOS65-Plus Rating 8 Type - Mental strain/tension (Y126e) HoNOS65-Plus Rating 8 Type - Dissociative (Y126f) HoNOS65-Plus Rating 8 Type - Somatoform (Y127a) HoNOS65-Plus Rating 8 Type - Eating (Y127b) HoNOS65-Plus Rating 8 Type - Sleep (Y127c) HoNOS65-Plus Rating 8 Type - Sexual (Y127d) HoNOS65-Plus Rating 8 Type - Other (Y127e)

980841000000104 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 9 - Problems with Scales 65+) rating scale 9 score - problems with relationships (Y125d) social or supportive relationships

980851000000101 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 10 - Problems with Scales 65+) rating scale 10 score - problems activities of daily living (Y125e) with activities of daily living

980861000000103 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 11 - Overall Scales 65+) rating scale 11 score - overall problems with living conditions (Y125f) problems with living conditions

980871000000105 HoNOS 65+ (Health of the Nation Outcome HoNOS65-Plus item 12 - Problems with Scales 65+) rating scale 12 score - problems activities (Y126a) with work and leisure activities - quality of daytime environment

989751000000102 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 1 - disruptive antisocial Scales for Children and Adolescents - clinician- aggressive behaviour (XaarB) rated) scale 1 score - disruptive, antisocial or aggressive behaviour

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 125 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

989801000000109 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 2 - overactivity, Scales for Children and Adolescents - clinician- attention and concentration (XaarC) rated) scale 2 score - overactivity, attention and concentration

989811000000106 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 3 - non-accidental self Scales for Children and Adolescents - clinician- injury (XaarD) rated) scale 3 score - non-accidental self injury

989821000000100 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 4 - alcohol, Scales for Children and Adolescents - clinician- substance/solvent misuse (XaarE) rated) scale 4 score - alcohol, substance/solvent misuse

989831000000103 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 5 - scholastic or Scales for Children and Adolescents - clinician- language skills (XaarF) rated) scale 5 score - scholastic or language skills

989841000000107 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 6 - physical illness or Scales for Children and Adolescents - clinician- disability problems (XaarG) rated) scale 6 score - physical illness or disability problems

989851000000105 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 7 - hallucinations and Scales for Children and Adolescents - clinician- delusions (XaarH) rated) scale 7 score - hallucinations and delusions

989861000000108 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 8 - non-organic somatic Scales for Children and Adolescents - clinician- symptoms (XaarI) rated) scale 8 score - non-organic somatic symptoms

989871000000101 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 9 - emotional and Scales for Children and Adolescents - clinician- related symptoms (XaarJ) rated) scale 9 score - emotional and related symptoms

989761000000104 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 10 - peer relationships Scales for Children and Adolescents - clinician- (XaarK) rated) scale 10 score - peer relationships

989771000000106 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 11 - self care and Scales for Children and Adolescents - clinician- independence (XaarL) rated) scale 11 score - self care and independence

989781000000108 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 12 - family life and Scales for Children and Adolescents - clinician- relationships (XaarM) rated) scale 12 score - family life and relationships

989791000000105 HoNOSCA-CR (Health of the Nation Outcome HoNOSCA item 13 - poor school Scales for Children and Adolescents - clinician- attendance (XaarN) rated) scale 13 score - poor school attendance

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 126 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

987711000000106 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 1 Score - behavioural Scales for People with Learning Disabilities) problems (directed at others) (Y133a) rating scale 1 score - behavioural problems (directed at others)

987811000000101 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 2 Score - behavioural Scales for People with Learning Disabilities) problems (directed towards self) (Y133b) rating scale 2 score - behavioural problems directed towards self (self-injury)

988261000000101 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 3A Score - behaviour Scales for People with Learning Disabilities) destructive to property (Y133c) rating scale 3A score - behaviour destructive to property

988271000000108 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 3B Score - problems Scales for People with Learning Disabilities) with personal behaviours (Y133d) rating scale 3B score - problems with personal behaviours

988281000000105 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 3C Score - rocking, Scales for People with Learning Disabilities) stereotyped and ritualistic behaviour rating scale 3C score - rocking, stereotyped and (Y133e) ritualistic behaviour

988291000000107 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 3D Score - anxiety, Scales for People with Learning Disabilities) phobias, obsessive, compulsive rating scale 3D score - anxiety, phobias, behaviour (Y133f) obsessive or compulsive behaviour

988301000000106 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 3E Score - other Scales for People with Learning Disabilities) behaviours (Y134a) rating scale 3E score - others

987831000000109 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 4 Score - attention Scales for People with Learning Disabilities) and concentration (Y134b) rating scale 4 score - attention and concentration

987841000000100 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 5 Score - memory Scales for People with Learning Disabilities) and orientation (Y134c) rating scale 5 score - memory and orientation

987851000000102 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 6 Score - Scales for People with Learning Disabilities) communication (problems with rating scale 6 score - communication (problems understanding) (Y134d) with understanding)

987861000000104 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 7 Score - Scales for People with Learning Disabilities) communication (problems with rating scale 7 score - communication (problems expression) (Y134e) with expression)

987871000000106 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 8 Score - problems Scales for People with Learning Disabilities) associated with hallucinations and rating scale 8 score - problems associated with delusions (Y134f) hallucinations and delusions

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 127 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

987881000000108 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 9 Score - problems Scales for People with Learning Disabilities) associated with mood changes (Y135a) rating scale 9 score - problems associated with mood changes

987721000000100 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 10 Score - problems Scales for People with Learning Disabilities) with sleeping (Y135b) rating scale 10 score - problems with sleeping

987731000000103 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 11 Score - problems Scales for People with Learning Disabilities) with eating and drinking (Y135c) rating scale 11 score - problems with eating and drinking

987741000000107 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 12 Score - physical Scales for People with Learning Disabilities) problems (Y135d) rating scale 12 score - physical problems

987751000000105 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 13 Score - seizures Scales for People with Learning Disabilities) (Y135e) rating scale 13 score - seizures

987761000000108 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 14 Score - activities Scales for People with Learning Disabilities) of daily living at home (Y135f) rating scale 14 score - activities of daily living at home

987771000000101 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 15 Score - activities Scales for People with Learning Disabilities) of daily living outside the home (Y136a) rating scale 15 score - activities of daily living outside the home

987781000000104 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 16 Score - level of Scales for People with Learning Disabilities) self care (Y136b) rating scale 16 score - level of self-care

987791000000102 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 17 Score - problems Scales for People with Learning Disabilities) with relationships (Y136c) rating scale 17 score - problems with relationships

987801000000103 HoNOS-LD (Health of the Nation Outcome HoNOS LD Rating 18 Score - Scales for People with Learning Disabilities) occupation and activities (Y136d) rating scale 18 score - occupation and activities

981391000000108 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating scale A - Scales-secure) rating scale A score - risk of potential harm to others (XaJMS) harm to adults or children

981401000000106 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating scale B - Scales-secure) rating scale B score - risk of potential self harm or neglect (XaJMT) self-harm (deliberate or accidental)

981411000000108 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating C - need for Scales-secure) rating scale C score - need for build secur to prev escape (XaJMU) buildings security to prevent escape

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 128 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

SNOMED - CT Preferred Term (SNOMED – CT) Read Code

981421000000102 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating D - need for Scales-secure) rating scale D score - need for safely staffed living env (XaJMV) safely staffed living environment

981431000000100 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating scale E - need Scales-secure) rating scale E score - need for for escort on leave (XaJMW) escort on leave (beyond secure perimeter)

981441000000109 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating F - poten harm Scales-secure) rating scale F score - risk to to individ frm others (XaJMX) individual from others

981451000000107 HoNOS-secure (Health of the Nation Outcome HoNOS-secure: Rating G - need for Scales-secure) rating scale G score - need for specialist clin procedures (XaJMY) risk management procedures

506701000000100 Patient health questionnaire 9 score Patient health questionnaire (PHQ-9) score (XaLDN)

860641000000108 Sheffield learning disabilities outcome measure Sheffield learning disabilities outcome score measure (XaZqU)

885541000000103 Warwick-Edinburgh Mental Well-being Scale Warwick-Edinburgh Mental Well-being score Scale (Xaacs)

M802911 Person Score The observable value (score) resulting from an assessment. SystmOne will automatically extract this numeric from the total scores of an MHCT assessment. MHS803 Care Cluster

M803919 Clustering Tool Assessment Identifier A unique identifier for each clustering tool assessment that takes place for each patient. This will be generated automatically by SystmOne.

M803020 Start Date (Care Cluster Assignment Period) The date on which the assignment of a patient to a Care Cluster started. In SystmOne this is recorded after completing a MHCT assessment in the New Cluster dialog, in the Start field.

M803030 Start Time (Care Cluster Assignment Period) The time on which the assignment of a patient to a Care Cluster started. In SystmOne this is recorded after completing a MHCT assessment in the New Cluster dialog, in the Start field.

M803010 Adult Mental Health Care Cluster Code (Final) Adult Mental Health Care Cluster Code (Final) is the code associated with the final cluster allocation following completion of an MHCT Assessment. In SystmOne this is recorded after completing a Adult Mental Health Clustering Tool Assessment (see m801010) in the New Cluster dialog, in the Cluster field. The below table shows a mapping from the SystmOne option for Clusters to the National Code output in the specification:

National Code Extract Description SystmOne Option

00 Care Cluster 0: Variance Care Cluster 0: Variance

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 129 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Option

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

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

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

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

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

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

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

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

09 Care Cluster 9: Cluster Under Review Care Cluster 9: Cluster Under Review

10 Care Cluster 10: First Episode Psychosis Care Cluster 10: First Episode Psychosis

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

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

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

14 Care Cluster 14: Psychotic Crisis Care Cluster 14: Psychotic Crisis

15 Care Cluster 15: Severe Psychotic Depression Care Cluster 15: Severe Psychotic Depression

16 Care Cluster 16: Dual Diagnosis Care Cluster 16: Dual Diagnosis

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

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

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

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

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 130 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Option

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

M803060 Child and Adolescent Mental Health Needs Based Grouping Code Child and adolescent mental health needs based grouping code is the needs based grouping code allocated to the child or young person by the care professional.

M803070 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. The determination of the learning disabilities care cluster code may or may not have involved the use of the National Tariff Payment System clustering algorithm. Please note that this data item is not currently in use, as specified in the NHS Digital MHSDS User Guidance V3.0.

M803080 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. In SystmOne this is recorded after completing a Forensic (Mental Health) Clustering Tool Assessment (see M801010) in the New Cluster dialog, in the Cluster field. The below table shows a mapping from the SystmOne option for Clusters to the National Code output in the specification:

National Code Extract Description SystmOne Option

00 Care Cluster 0: Variance Care Cluster 0: Variance

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

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

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

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

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

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

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

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

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

09 Care Cluster 9: Cluster Under Review Care Cluster 9: Cluster Under Review

10 Care Cluster 10: First Episode Psychosis Care Cluster 10: First Episode Psychosis

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 131 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

National Code Extract Description SystmOne Option

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

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

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

14 Care Cluster 14: Psychotic Crisis Care Cluster 14: Psychotic Crisis

15 Care Cluster 15: Severe Psychotic Depression Care Cluster 15: Severe Psychotic Depression

16 Care Cluster 16: Dual Diagnosis Care Cluster 16: Dual Diagnosis

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

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

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

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

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

M803090 Forensic Learning Disabilities Care Cluster Code (Final) Forensic learning disabilities care cluster code (final) is the final allocation of the forensic care cluster code by the care professional. The determination of the forensic care cluster code may or may not have involved the use of the National Tariff Payment System clustering algorithm. Please note that this data item is not currently in use, as specified in the NHS Digital MHSDS User Guidance V3.0.

M803040 End Date (Care Cluster Assignment Period) The date on which the assignment of a patient to a Care Cluster ended. In SystmOne this is the End Date recorded on the New Cluster dialog, or right clicking on an existing Cluster and select End, in the Cluster Allocation node.

M803050 End Time (Care Cluster Assignment Period) The time on which the assignment of a patient to a Care Cluster ended. In SystmOne this is the End Date recorded on the New Cluster dialog, or right clicking on an existing Cluster and select End, in the Cluster Allocation node.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 132 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS804 Five Forensic Pathways

M804901 Local Patient Identifier (Extended) This number uniquely identifies the patient within the Health Care Provider system. SystmOne will extract this information automatically.

M804010 Five Forensic Pathways Assessment Date The date on which a Five Forensic Pathways assessment was completed for a patient. This is recorded using the date of the CTV3 Read code Five Forensic Pathways Assessment (Y181b).

M804020 Five Forensic Pathways Assessment Reason The reason for which a Five Forensic Pathways assessment was undertaken. This will be recorded using CTV3 Read codes.

National Code Extract Description SystmOne Read code mapping

10 Initial Assessment 5FP - Initial Assessment (Y181c)

11 Scheduled Re-Assessment 5FP - Scheduled Re-Assessment (Y181d)

12 Re-Assessment following significant 5FP - Re-Assesment following unanticipated change in need significant unanticipated change in need (Y181e)

97 Other Reason 5FP - Other reason (Y181f)

99 Not known (Not Recorded) 5FP - Not known (not recorded) (Y182a)

M804030 Five Forensic Pathways Code The Five Forensic Pathway assigned to a patient. This will be recorded using CTV3 Read codes. Note: If multiple Read codes are recorded, there will be multiple rows in the extract.

National Code Extract Description SystmOne Read code mapping

0 Unable to assign patient to one of the five Unable to assign patient to one of the forensic pathways five forensic pathways (Y183b)

1 Treatment responsive group 5FP - Treatment responsive group (Y182c)

2 Treatment resistant group – challenging 5FP - Treatment resistant group - behaviour challenging behaviour (Y182d)

3 Treatment resistant group – continuing care 5FP - Treatment resistant group - continuing care (Y182e)

4 Personality disorder group – prison transfer 5FP - Personality disorder group - prison transfer (Y182f)

5 Personality disorder group – co-morbidity 5FP - Personality disorder group - co- morbidity (Y183a)

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 133 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

MHS901 Staff Details

M901908 Care Professional local identifier This is a unique local Care Professional identifier within a Health Care Provider. SystmOne automatically extracts this information.

M901010 Professional Registration Body Code This is a code which identifies the professional registration body or representative body of a staff member, for example General Medical Council. This is extracted via the selection made on the National ID field in Amend Staff Details.

M901020 Professional Registration Entry Identifier The registration identifier allocated by an organisation. This is the ID recorded against the National ID field in Amend Staff Details.

M901030 Care Professional Staff Group (Mental Health) The staff group of a Care professional working in mental health service. Within SystmOne it’s not possible to capture a care professional staff group. This field is therefore not supported and will not be extracted.

M901040 Main Specialty Code (Mental Health) This is the main specialty code of the mental health responsible clinician for the patient within the reporting period. This is recorded against the staff profile on SystmOne by going to the Skill Sets, Specialties and Treatment Codes tab of the Amend Staff Details dialog. This is accessed by going to Setup>Users& Policy>Staff & Organisation Setup and right clicking Amend on your profile name.

National Code Extract Description SystmOne Read code mapping

600 General Medical Practice General medical practice

700 Learning Disability Learning disability

710 Adult Mental illness Adult mental illness

711 Child and Adolescent Psychiatry Child and adolescent psychiatry

712 Forensic psychiatry Forensic psychiatry

713 Psychotherapy Psychotherapy

715 Old age psychiatry Old age psychiatry

950 Nursing Episode Nursing episode

960 Allied Health Professional Episode Allied health professional episode

M901050 Occupation Code This is an NHS occupation code for an employee. Users can find their code in the NHS Occupation Code Manual and add it to the Occupation Code field on the Skill Sets, Specialties and Treatment Codes tab of the Amend Staff Details dialog. This is accessed by going to Setup>Users& Policy>Staff & Organisation Setup and right clicking Amend on your profile name. If a configured list option for your role does not already exist a System Administrator at your unit can add one by going to Configured Lists, selecting the organisation group they wish to create the preference for and navigating to Admin>Occupation Codes and then selecting New Option. They will then be able to add a new configured list option and map it to the relevant occupation code for MHSDS by clicking on the + symbol on the Select National Codes dialog and choosing Select MHSDS National Code.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 134 These instructions are correct at the date of writing. For further assistance, consult the SystmOne Online Help.

M901060 Care Professional (Job Role Code) This is a national code for a position applicable to an employee. SystmOne will automatically map this based on the Employment role selected on the Local Settings tab of the Amend Staff Details dialog.

©TPP 2018 – Commercial in confidence Please note: All patient data shown in this document is fictitious. 135