For reference only Do Not Use For more information contact: Mental Health

For reference only Do Not Use For more information contact: cdsis@nhs.net Mental Health National Datasets for Care Information Sharing: Information Core for Integrated Care Psychiatric Inpatient Clinical Discharge Summary September 2006 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7053 Email to: NCDDPsupportteam@isd.csa.scot.nhs.uk Website: www.clinicaldatasets.scot.nhs.uk

Section 1 Background & Overview... 4 1.1. The Improving Mental Health Information Programme...5 1.1.1. Why have the Programme?...5 1.1.2. What s the Programme doing?...5 1.1.3. Access to currently collected nationally consistent information...5 1.1.4. Network building and knowledge sharing...5 1.1.5. Developing a mental health information strategy for Scotland s future...5 1.2. The National Clinical Dataset Development Programme...5 1.2.1. Mental Health Care Information Sharing Datasets...6 1.2.2. Background to NCDDP...6 1.2.3. Approval & Publication...6 1.2.4. Clinical Terminology...7 1.2.5. Data Recording...7 1.3. The Information Core for Integrated Care...8 1.3.1. What is the Information Core for Integrated Care?...8 1.3.2. Progress to Date...8 1.3.3. What information does the ICIC contain?...8 1.3.4. Next Steps...9 1.3.5. What is the relationship between the ICIC and Single Shared Assessment?...9 1.4. The Psychiatric Inpatient Clinical Discharge Summary...11 1.4.1. What is the Psychiatric Inpatient Clinical Discharge Summary?...11 1.4.2. What information does the PIC-DSIS contain?...11 1.4.3. Progress to Date...12 1.4.4. Next Steps...12 Section 2 - The Information Core for Integrated Care Dataset... 13 2.1. Person Summary (Core)...13 2.1.1. Patient Administration and Demographics...13 2.1.2. Ethnic, Cultural and Diversity...14 2.1.3. Risks and Alerts (including communication)...14 2.1.4. Socio-Environmental Details...14 2.1.5. Background Health Information...15 2.1.6. Associated Person Details...15 2.1.7. General Medical Practitioner Details...16 2.1.8. Associated Professional Details...18 2.2. Person Summary {Mental Health}...20 2.2.1. Risk Factors...20 2.2.2. Care Programme Approach...20 2.2.3. Legal Data...20 2.3. Encounter Summary {Mental Health}...21 2.3.1. Care Episode Administration Details...21 2.3.2. Health Problems and Diagnosis {Mental Health}...22 2.3.3. Personal History of Interventions {Mental Health}...23 2.3.4. Medication...23 Section 3 - Information Core for Integrated Care Data Items for Consultation. 23 3.1. Person Summary (Core) Data Items for Consultation...23 3.1.1. Live Alone Indicator...23 3.1.2. Comments about Associated Person...23 3.1.3. Associated Professional Group {Mental Health}...24 3.1.4. Keyworker Indicator...24 3.1.5. Care Team Type {Mental Health}...24 3.1.6. Associated Professional Role {Mental Health}...24 3.2. Person Summary {Mental Health} Data Items for Consultation...25 3.2.1. Structured Risk Assessment Status...25 3.2.2. Risk Summary...25 3.2.3. Risk Status Level...26 3.2.4. Risk History...26 3.2.5. Known Triggers...29 3.2.6. Risk History Comments...29 3.2.7. Birth of Child in last 12 Months...29 3.2.8. Advance Statement Availability...30 3.2.9. Advance Statement Location...30 3.3. Encounter Summary {Mental Health} Data Items for Consultation...31 3.3.1. Contact Location Type {Mental Health}...31 3.3.2. Assessed Priority of Appointment...31 3.3.3. Contact Purpose {Mental Health}...31 Mental Health Datasets Page 1

3.3.5. Life/Social Difficulties Identified...33 3.3.6. Diagnosis {Mental Health} - Primary Psychiatric Diagnosis...33 3.3.7. Diagnosis {Mental Health} - Other Psychiatric Diagnoses...34 3.3.8. Certainty of Diagnosis...35 3.3.9. Physical Health Problems...35 3.3.10. Identified Problems/ Issues Comments...35 3.3.11. Personal History of Interventions {Mental Health} Summary...36 3.3.12. Personal History of Interventions {Mental Health}...36 3.3.12.1. Assessment... 36 3.3.12.2. Care Planning and Review... 37 3.3.12.3. Social Circumstances Support... 38 3.3.12.4. Health Promotion and Management... 42 Medical Investigations... 43 3.3.12.5. Medication Management... 43 3.3.12.6. Physical Therapies... 43 3.3.12.7. Psychosocial Approaches... 45 3.3.12.8. Legal Actions... 48 3.3.12.9. Risk Management... 49 3.3.12.10. Activities of Daily Living Support... 50 3.3.12.11. Spiritual Support... 50 3.3.12.12. Intervention / Type of Care Delivered Comments... 51 3.3.13. Next Steps...51 3.3.14. Date of Next Appointment...52 3.3.15. Time of Next Appointment...52 3.3.16. Arrangements for Aftercare Comments...52 3.3.17. Patient/ Client Comments...52 Section 4 The Psychiatric Inpatient Clinical Discharge Summary Dataset... 52 4.1. Person Summary (Core)...53 4.1.1. Patient Administration and Demographics...53 4.1.2. Ethnic, Cultural and Diversity...54 4.1.3. Risks and Alerts (including communication)...54 4.1.4. Socio-Environmental Details...55 4.1.5. Background Health Information...55 4.1.6. Associated Person Details...55 4.1.7. General Medical Practitioner Details...56 4.1.8. Associated Professional Details...57 4.2. Person Summary {Mental Health}...59 4.2.1. Risk Factors...59 4.2.2. Legal Data...60 4.3. Admission/ Transfer {Mental Health}...60 4.4. Health Problems and Diagnosis {Mental Health}...60 4.5. Personal History of Interventions {Mental Health}...61 4.6. Discharge {Mental Health}...61 4.6.1. Medication at Discharge...61 4.6.2. Discharge Details...61 Section 5 - Psychiatric Inpatient Clinical Discharge Summary Data Items for Consultation... 63 5.1. Person Summary (Core) Data Items for Consultation...63 5.1.1. Lives Alone Indicator...63 5.1.2. Comments about Associated Person...63 5.1.3. Clinician Role {Mental Health}...63 5.1.4. Grade of Doctor...63 5.1.5. Clinician Specialty {Mental Health}...64 5.1.6. Associated Professional Group...65 5.1.7. Keyworker Indicator...65 5.1.8. Associated Professional Role {Mental Health}...65 5.2. Person Summary {Mental Health} Data Items for Consultation...66 5.2.1. Structured Risk Assessment Status...66 5.2.2. Risk Summary Status...66 5.2.3. Risk Status Level...67 5.2.4. Risk History...67 5.2.5. Known Triggers...69 5.2.6. Risk Comments...70 5.2.7. Birth of Child in last 12 Months...70 5.2.8. Advance Statement Availability...70 5.2.9. Advance Statement Location...71 5.3. Admission/ Transfer {Mental Health} Data Items for Consultation...72 Mental Health Datasets Page 2

5.3.1. Date of Admission/ Transfer...72 5.3.2. Admission/ Transfer Reason {Mental Health}...72 5.3.3. Admission Type {Mental Health}...73 5.3.4. Admission/ Transfer Comments...74 5.4. Health Problem and Diagnosis {Mental Health} Data Items for Consultation...74 5.4.1. Health Problem Identified {Mental Health}...74 5.4.2. Life/Social Difficulties Identified...75 5.4.3. Diagnosis {Mental Health} Primary Psychiatric Diagnosis...75 5.4.5. Diagnosis {Mental Health} Other Psychiatric Diagnoses...76 5.4.6. Certainty of Diagnosis...77 5.4.7. Physical Health Problems...77 5.4.8. Identified Problems/ Issues Comments...77 5.5. Personal History of Interventions {Mental Health} for Consultation...78 5.5.1. Personal History of Interventions {Mental Health} Summary...78 5.5.2. Personal History of Interventions {Mental Health}...78 5.5.2.1. Assessment... 78 5.5.2.2. Care Planning and Review... 79 5.5.2.3. Social Circumstances Support... 80 5.5.2.4. Health Promotion and Management... 84 5.5.2.5. Medication Management... 85 5.5.2.6. Physical Therapies... 85 5.5.2.7. Psychosocial Approaches... 87 5.5.2.8. Legal Actions... 90 5.5.2.9. Risk Management... 91 5.5.2.10. Activities of Daily Living Support... 92 5.5.2.11. Spiritual Support... 92 5.5.2.12. Intervention / Type of Care Delivered Comments... 93 5.6. Discharge {Mental Health} Data for Consultation...93 5.6.1. Medication at Discharge...93 5.6.2. Discharging Hospital - Name...94 5.6.3. Discharging Hospital Name of Ward/ Department...94 5.6.4. Discharge/ Transfer to (Discharge Destination)...94 5.6.5. Discharge Type...95 5.6.6. Disability at Discharge...96 5.6.7. Mobility at Discharge...96 5.6.8. Discharge Letter to Follow...96 5.6.9. Results Awaited...97 5.6.10. Sickness Certificate Issued...97 5.6.11. Arrangements for Aftercare Comments...97 5.6.12. Patient/ Client Comments...98 Appendix I Acronyms and Abbreviations... 99 Appendix II Working Group Membership... 100 Appendix III - Consultation Distribution List... 102 Mental Health Datasets Page 3

Section 1 Background & Overview The Improving Mental Health Information Programme supports the development and implementation of the Information Core for Integrated Care and Psychiatric Inpatient Clinical Discharge Summary datasets in order to ensure a national approach to the collection of clinical and non-clinical information relating to the care of mental health service users. The aim of the datasets is to support the implementation of an integrated health record and ensure inter-compatibility of national clinical and social care information systems. National data standards will also support data sharing with other agencies through agreed protocols. Two multidisciplinary working groups supported by the National Clinical Dataset Development Programme met during 2005 to refine and agree the content of each dataset. Membership is shown in Appendix II. The Data Standards Branch of the Scottish Executive Data Sharing & Standards Division (formerly the Social Care Data Standards Project) has been closely involved in the construction of the datasets and data standards presented in this paper, and fully endorses their use for the purposes of electronic Mental Health information sharing which involves Social Care practitioners and agencies. The Mental Health datasets will: Define common data items recommended for collection in a wide variety of clinical settings Support the exchange of patient information between health and social care providers Support the consistent recording of patient information throughout NHS Scotland The Information Core for Integrated Care will: Provide nationally consistent and standardised information on encounters and interventions with adult community mental health services Allow members of a joint care team (including social work, health, non-statutory and other agencies) to have access to basic shared information on what care is being delivered Improve information sharing and aid delivery and continuity of inter-disciplinary multi-agency care The Psychiatric Inpatient Clinical Discharge Summary will: Provide nationally consistent and standardised information on discharge from psychiatric hospital Support transitions in care and help ensure a smooth discharge from psychiatric hospital Enable SMR04 to eventually be replaced with information derived from a clinical discharge summary We are now looking for feedback from the wider mental health community in order to ensure that the datasets are fit for purpose and ready for implementation and inclusion in the health and social care data dictionary. We invite all interested organisation and individuals to take part in this consultation by completing the attached consultation response form (Appendix IV) and then returning it to NCDDPsupportteam@isd.csa.scot.nhs.uk. Comments on all or part of the document are welcome. Mental Health Datasets Page 4

1.1. The Improving Mental Health Information Programme 1.1.1. Why have the Programme? Better information is required to allow better decisions to be taken and better care to be delivered. The Information Services Directorate (ISD) of NHS National Services Scotland has therefore established a mental health information programme. Information on mental health problems and on service delivery is required to support: comprehensive, joined-up care for individual users of mental health services; improvements in quality of mental health services; and strategic planning, public health, performance management, and research. Experience shows that information for quality improvement and planning is most likely to be accurate and reliable if it is derived from information shared among care-providers for their own use. 1.1.2. What s the Programme doing? The programme has three interlinked strands. These aim to improve access to current data, share knowledge around Scotland, and develop a mental health information strategy for Scotland s future. 1.1.3. Access to currently collected nationally consistent information We have surveyed the currently collected national data and made recommendations for how to close gaps. Our team of analysts continue to provide an informed response to requests for mental health information to support policy making, audit and research. 1.1.4. Network building and knowledge sharing We organise national meetings and a variety of workshops to allow exchange of perspectives and experience on aspects of electronic shared care records. Information managers, service users and care providers from across Scotland have participated and reports are available at our website. We also publish electronic monthly newsletters (available at our website: http://www.isdscotland.org/imhip). 1.1.5. Developing a mental health information strategy for Scotland s future In partnership with colleagues in the Scottish Executive Health Department we are working on a Mental Health Information Strategy for Scotland 1. The strategy recognises that progress is required in three areas: Development of an information culture within care organisations that values teamwork, trusts data and respects colleagues opinions, and that appreciates the benefits of information gathering, use and sharing. We are addressing these complex issues through the workshops described above. Agreement on minimal information sets 2 to be shared to support joined-up community care for individuals. We have developed an Information Core for Integrated Care (ICIC), and a standardised discharge summary. These are designed to support improved inter-agency multi-disciplinary mental health care provision and we are now piloting these approaches. Defining the core functions of electronic information systems to support delivery of mental health care. We have developed a high level functional specification and are using this to assist NHS boards and partners procure and develop appropriate systems. 1.2. The National Clinical Dataset Development Programme 1 A copy of the Mental Health Information Strategy can be downloaded from http://www.isdscotland.org/imhip_mhis 2 These information sets are the Information Core for Integrated Care and Psychiatric Clinical Inpatient Discharge Summary which we are consulting on in this paper Mental Health Datasets Page 5

1.2.1. Mental Health Care Information Sharing Datasets The membership of both the Information Core for Integrated Care and Psychiatric Inpatient Clinical Discharge Summary multidisciplinary working group is shown in Appendix II. The working groups agreed the inclusion of individual data items using the following criteria: 1. Is the data item one that should be collected and used by mental health care providers? 2. Is the data item necessary for the on-going health and social care of mental health service users in contact with community specialist services or admitted to psychiatric hospital? 3. Is the data likely to be shared among health and social care professionals (as justified by clinical need and patient consent)? This consultation seeks feedback on the content of the datasets, to ensure they are fit for purpose and meet the needs of care providers. During the consultation phase the datasets will also be implemented in test areas across Scotland in order to gain a better understanding of the barriers to collection and sharing of the information. The collection of the datasets real-time into existing systems will enable us to obtain feedback on the content of the datasets through people s real life experience of collecting the information, in addition to that received through this consultation process. Once consultation and test implementation is complete both multidisciplinary working groups will meet to approve suggested changes to both datasets. The Information Core for Integrated Care and Psychiatric Inpatient Clinical Discharge Summary will then be submitted to the NCDDP Programme Board for formal approval as national standards, and then will subsequently be passed to the ehealth National Clinical Information Steering Group and the NHS Scotland Information Standards Group for endorsement. Once approved both datasets will be freely and widely available through publication in the Health and Social Care Data Dictionary. The datasets will be implemented within existing and emerging national clinical information systems (including commercially-procured national products) as well as being available to other commercial developers to ensure the ability of their systems to support national information requirements. 1.2.2. Background to NCDDP To date, much of the data collected in NHS Scotland in a nationally consistent way has been through central returns to ISD relating to patient administrative and demographic data and NHS activity data - the content of the SMR Data Manual and the Definitions and Codes Manual reflect this. A limited amount of clinical information is collected at national level, mostly describing diagnoses, operations and procedures and the small number of national audits. Such information is not usually automatically generated as a by-product of operational clinical information, but may require intensive data collection that is quite discrete from any patient care process. There is now a drive from many clinical bodies to collect more meaningful clinical information, in particular to inform clinical audit and clinical governance requirements. Information Management and Technology (IM&T) development within NHS Scotland is accelerating and more clinicians are now embracing electronic means of recording clinical information, particularly in primary care. The move towards an integrated care record (ICR) with the availability electronically of appropriate clinical information to health care professionals for direct patient care purposes is one of the key aims of the National e-health Strategy (April 2004). Electronic integration of clinical information, facilitating appropriate sharing and communication of information is desirable, particularly for the care of patients with chronic disease. Good clinical information systems are required which support direct patient care in this way, whilst also generating secondary information, such as that required for audit, as a by product where possible. The ability to link patient data across journeys of care requires alignment of clinical data standards across specialties, including their coding schema and clinical definitions. The NCDDP Programme was established in 2003 in response to the health white paper Partnership for Care (February 2003), to provide coordination and support at a national level for the clinically led development of national clinical data standards. The goal is to develop a set of interoperable national datasets initially focusing on the clinical priority areas. More information can be found on our website www.clinicaldatasets.scot.nhs.uk 1.2.3. Approval & Publication Mental Health Datasets Page 6

Following consultation, the Information Core for Integrated Care and the Psychiatric Inpatient Clinical Discharge Summary will be submitted to the NCDDP Programme Board for formal approval as national datasets and subsequently passed to the ehealth National Clinical Information Steering Group and the NHS Scotland Information Standards Group for endorsement. Both datasets will then be freely and widely available through publication in the Health and Social care data dictionary. As far as possible they are UK compatible. It is recommended that these datasets should be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. 1.2.4. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. This work will be commenced once SNOMED CT tools become available. 1.2.5. Data Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include date stamping as standard functionality, therefore Mental Health Information Sharing Datasets do not deal with this issue. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The Information Core for Integrated Care and the Psychiatric Inpatient Clinical Discharge Summary conforms to the Government Data Standards Catalogue format for date recording: CCYY-MM-DD. However, the underlying data structure does not preclude entry of data using the traditional DD-MM-CCYY format. Mental Health Datasets Page 7

1.3. The Information Core for Integrated Care 1.3.1. What is the Information Core for Integrated Care? The Information Core for Integrated Care (ICIC) is an encounter and intervention dataset intended to be collected electronically at each significant encounter with adult 3 community specialist mental health services. The ICIC captures information on who was seen where, by whom, what was wrong (diagnosis/ symptoms), what was done (interventions), and what is going to happen next. Its purpose is to allow members of a joint care team (including social work, health, non-statutory and other agencies) to have access to basic shared information on what care is being delivered. Such information aids delivery and continuity of inter-disciplinary multi-agency care. 1.3.2. Progress to Date The concept of an ICIC was initially developed by the Improving Mental Health Information Programme through a series of discussions with mental health services throughout Scotland. In 2003, as a first step to testing the robustness of the dataset, it was decided to run a retrieval pilot in 3 NHS Board areas (each using a different information system). The findings from the retrieval pilot showed that there was rich data for some data items, however poor data for data items such as ethnicity, significant social factors, professional registration ID, reason for referral, current problems, diagnosis, intervention and what next/ follow up. For some data items, ICIC did not capture all the data categories and map them to the pick lists/ drop down menus, therefore further definitional work was required for some data items. The retrieval pilot showed that the ICIC presents an opportunity to track the patient s journey in the community, and provide better information on encounters and interventions. The design of the tool reflects the continued growth in joint working between health and social care, to deliver a better standard of care. The ICIC has the scope to provide valuable mental health care information, which can inform policy makers and budget holders. In December 2004 a project manager was appointed to take forward real-time test implementation of the ICIC. At the beginning of 2005 a multi disciplinary working group (including service users and carers) was established to refine the content of the dataset, and undertake further work on the content of the data items (definitions and categories). Membership of the group, which met monthly from March to October 2005 can be seen at appendix II. 1.3.3. What information does the ICIC contain? The ICIC contains person summary and encounter summary information. It is likely that in most areas the majority of the person summary information e.g. admin and demographics will already be captured and held within systems for other purposes. It is intended that this information will not be collected separately for the ICIC, but rather the information that is already contained within existing systems, or collected for other purposes such as single shared assessment can be pulled across and populate the relevant fields of the ICIC to avoid duplication of recording. The ICIC incorporates nationally agreed health and social care recording standards 4 where possible which means that over time any data item which is collected electronically will have to conform to these standards, thus facilitating the move towards one patient, one record. The encounter summary information will capture information on encounters and interventions with service users and care providers. Over time the collection of encounter and intervention information will build up an encounter history between the community specialist team and service user. It is hoped that this encounter history will be able to be accessed routinely by community mental health 3 The development of the ICIC has initially concentrated on adult community specialist mental health services, and will be test implemented in this area. Over time we hope to refine the content to ensure it meets the needs of other age groups including old age and CAMH services and specialised teams such as drug and alcohol services. 4 Nationally agreed health and social care data standards are published in the Health and Social Care Data Dictionary www.datadictionary.nhs.scot.uk Mental Health Datasets Page 8

teams (CMHTs) (where appropriate) in order to aid care delivery, particularly during times of crisis out-of-hours when key information can often be difficult to access. Table 1 - Information contained within the ICIC Admin and demographics Living arrangements Lifestyle factors e.g. smoking PERSON SUMMARY (CORE) / SINGLE SHARED ASSESSMENT PERSONAL DETAILS Allergies and intolerances Ethnic/cultural information 1. Person Socio-economic circumstances Summary Physical health problems Mental health diagnosis Life/ social difficulties PERSON SUMMARY (MENTAL HEALTH) Associated professional details Mental health problems/ symptoms Risk Factors ENCOUNTER ENCOUNTER ENCOUNTER ENCOUNTER ENCOUNTER 2. Mental Health Encounter Summary Who saw Where/ when seen Why seen What done What next Who saw Where/ when seen Why seen What done What next Who saw Where/ when seen Why seen What done What next Who saw Where/ when seen Why seen What done What next Who saw Where/ when seen Why seen What done What next 1.3.4. Next Steps We are now consulting on the content of the Information Core for Integrated Care to ensure it can evolve to become an encounter and intervention dataset that is fit for purpose for implementation across adult community specialist services in Scotland. In addition to this consultation process, the ICIC will also be test implemented (collected real time ) into existing mental health systems by 3 CMHTs for a 3-month period commencing February 2006. Health Board areas participating in test implementation are Borders, Dumfries and Galloway and Ayrshire and Arran. The objectives of test implementation are: To identify and reduce barriers to the collection of ICIC using existing mental health systems. To facilitate information sharing. To improve information mindedness and support joined up working by CMHTs. To provide community information currently in deficit. To determine the usefulness of the data at national and local level. To assess whether the ICIC is fit for purpose and sufficiently robust for rollout across Scotland. Test implementation will be evaluated and it is hoped to produce a final report by the end of Summer 2006. 1.3.5. What is the relationship between the ICIC and Single Shared Assessment? The Joint Future Group Report Community Care: A Joint Future (November 2000) recommended the introduction of Single Shared Assessments from 1 October 2001. The definition of SSA is a person-centred and needs-led assessment, which relates to the individuals level of need. It is those Community Care Assessments that require input and co-ordination across agencies (or from a joint team) and where the assessment information has been shared between the appropriate staff in the agencies, by whatever method, in order to complete the assessment and/or secure services as a result. Mental Health Datasets Page 9

SSA takes a holistic and structured approach to the assessment process that supports joint working and provides results acceptable to all agencies. It enables nationally agreed assessment information to be shared between professionals and agencies appropriately. The purpose of SSA is to provide a process by which assessment information is collected once in order to provide a faster track to services, a faster journey along the tracks and a single point of entry to community care services. The introduction of SSA has led to less bureaucracy, duplication and delay in access to community care services. It has also facilitated joint working and actively involved people who use services and their carers. Although implementation of SSA initially concentrated on the over 65 age group it covers all community care groups who meet the criteria, including mental health service users in contact with adult community specialist services. Many of the service users in contact with joint teams such as CMHTs will therefore have shared assessment information collected and accessed by health and social care members of CMHTs involved in their care. Given that it is in the same joint teams we hope to implement the ICIC encounter and intervention dataset it is important to ensure that, where there are overlaps, the way in which the information is recorded (the data item content) is the same to avoid duplication of recording. The ICIC is not assessment information, but rather encounter and intervention information that will be collected electronically once the initial SSA and specialist assessment have been carried out. However some of the ICIC information is the same as that collected during the SSA process. The personal details section of the Single Shared Assessment (SSA) captures all of the core person summary information within the ICIC using the same agreed health and social care data standards. Rather than reinvent the wheel we would hope that person summary information captured electronically through the SSA process could feed the ICIC summary, and vice versa to avoid duplication recording. In addition some of the data items that are contained within the ICIC as supplementary information to the encounter summary are likely to captured at the initial assessment stage. For example information on impairment is contained within both the ICIC and SSA, but is more likely to be collected during the assessment process. As a structured recording standard exists for the collection of this information within SSA we have adopted this for the ICIC so that this information only has to be collected once and can be used for different purposes. Mental Health Datasets Page 10

1.4. The Psychiatric Inpatient Clinical Discharge Summary 1.4.1. What is the Psychiatric Inpatient Clinical Discharge Summary? The Psychiatric Inpatient Discharge Summary Information Set (PIC-DSIS) is an information sharing dataset intended to be completed incrementally throughout the inpatient episode. This incremental approach will facilitate easier information sharing and when a service user is transferred or discharged this immediate information bundle will support their transition in care. It is also hoped to eventually replace the current administrative return (SMR04) with information sourced from the PIC-DSIS dataset. 1.4.2. What information does the PIC-DSIS contain? The PIC-DSIS contains person summary, intervention(s) delivered during the inpatient stay and admission/ discharge summary information. It is likely that in most areas the majority of the person summary information e.g. admin and demographics will already be captured and held within systems for other purposes, and can populate the PIC-DSIS to avoid duplication of recording where possible. The PIC-DSIS incorporates nationally agreed health and social care recording standards 5 where possible which means that over time any data item which is collected electronically will have to conform to these standards, thus facilitating the move towards one patient, one record. The intervention information will capture information on the main types of care the patient/ client has received during their inpatient stay. Admission and discharge information will provide key information to smooth the transition of care during discharge. A consistent approach with the ICIC dataset has been applied hence the many similarities. The main differences are in the admission/transfer and discharge sections. The dataset contains information on the following areas: Service user details Associated person details Admission/transfer data Associated professionals Legal data Risk factors Current problems Interventions Medication data Discharge data 5 Nationally agreed health and social care data standards are published in the Health and Social Care Data Dictionary www.datadictionary.nhs.scot.uk Mental Health Datasets Page 11

Table 2 - Information contained within the PIC-DSIS Admin and demographics Living arrangements Lifestyle factors e.g. smoking PERSON SUMMARY (CORE) / SINGLE SHARED ASSESSMENT PERSONAL DETAILS 1. Person Summary Allergies and intolerances Ethnic/cultural information Socio-economic circumstances Physical health problems Mental health diagnosis Life/ social difficulties PERSON SUMMARY (MENTAL HEALTH) Associated professional details Mental health problems/ symptoms Risk Factors 2. Psychiatric Hospital Inpatient Summary ADMISSION When admitted Why admitted Legal Status at admission Problem(s) at admission INTERVENTION(S) Who saw What done DISCHARGE When discharged Where discharged from and to Legal Status at discharge Problem(s) at discharge Medication at discharge Follow up arrangements 1.4.3. Progress to Date A short-life working group was formed in 2004 comprising of service users and providers such as GPs, a social work manager, a psychologist, psychiatrist, nurses, information and service managers and dataset developers. The group developed the dataset in liaison with the National Clinical Dataset Development Programme (NCDDP) incorporating nationally agreed health and social care recording standards. A list of the short-life working group can be found in appendix II. A Project Manager has been appointed to recruit test implementation sites. Initial interest has been expressed by Grampian, Western Isles and Lothian Health Boards. 1.4.4. Next Steps Once sites have confirmed their intent to progress with the test implementation, gap analyses will require to be done on existing systems by the project manager and local staff. The dataset will then be tested in 2-3 psychiatric hospitals during Spring 2006. The objectives of the test implementation are to: Identify and reduce barriers to collection of PIC-DSIS using existing or novel mental health IT systems Facilitate information sharing Improve information mindedness Provide discharge summary information currently in deficit Support joined up team working and ease transition in care Determine the usefulness of these data at local and national level Assess whether the PIC-DSIS is fit for purpose and sufficiently robust for rollout across Scotland Test implementation will be evaluated and a final report produced by late Summer 2006. Mental Health Datasets Page 12

Section 2 - The Information Core for Integrated Care Dataset Tables 3 to 14 on the following pages list all data items contained within the ICIC dataset. Throughout the dataset we use the term Patient/ Client to refer to a patient, client or service user. Data recording standards for many of the generic data items have already been consulted on by the NCDDP, and many are now published within the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk. For this reason we are only seeking comment on the content of data items that are labelled with. However we are keen to gain feedback on the appropriateness of the inclusion of all data items within the relevant datasets, and invite you to do so using the form on Appendix IV. 2.1. Person Summary (Core) 6 2.1.1. Patient Administration and Demographics 7 Table 3 Patient Administration and Demographics Table Data Item Definition Format & Field length CHI Number The Community Health Index (CHI) is 10 characters a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Health Record Identifier A Patient Health Record Identifier is 14 characters a code (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS. Person Birth Date The date on which a person was born or is officially deemed to have 10 characters (CCYY- MM-DD) been born. Person Full Name (unstructured) This alternative to recording structured name involves the whole name being recorded as a single character string with no separately 70 characters Structured Name 8 - Person Family Name - Person Given Name - Person Preferred Forename - Previous Family name identified elements. An ordered sequence of person name elements such as title, forename(s) and family name. 35 characters per element 6 It is hoped that much of the Person Summary information contained within the following tables will already be held electronically within existing health and social systems. 7 All data items (unless marked with a ) in the table above are existing nationally approved Generic Data Standards for health and/ or social care. They are published in the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk which contains further information such as data categories and recording guidance. 8 It is recommended that Structured Name should be used in all new IT systems. Person Full Name (Unstructured) should only be used in legacy systems, which should migrate to use of Structured Name in due course. Mental Health Datasets Page 13

Table 3 continued 9 Data Item Definition Format & Field length Address (BS7666) 10 A collection of data describing the addressing of locations see Government Data Standards Catalogue Website 11 Postcode The code allocated by the Post Office 8 characters to identify a group of postal delivery points. UK Telephone Number A minimum standard is provided for 35 characters holding a UK STD code. An extended set of component parts is provided for systems to hold more information. Internet Email Address The string of characters that identifies an addressee's post box on the internet. 255 characters 2.1.2. Ethnic, Cultural and Diversity Table 4 - Ethnic, Cultural and Diversity Data Item Definition Format & Field length Sexual Orientation An [individual s] orientation towards 2 characters persons of the same sex (this covers gay men and lesbians); the opposite sex (this covers heterosexual men and women); or both sexes (this covers bisexual men and women). This should be self assigned. Ethnic Group (Self Assigned) A statement made by the service Up to 6 characters (2 + 4) user about their current ethnic group. Preferred Language This data item is defined as the Up to 6 characters person s language of preference and may differ from first language. It is required for effective communication with the person. Person Current Gender A statement by the individual about 1 character the gender they currently identify themselves to be (i.e. self-assigned). Religion A statement made by the service user about their current religious affiliation / Faith community. Up to 6 characters (2 + 4) 2.1.3. Risks and Alerts (including communication) Table 5 - Risks and Alerts (including communication) Data Item Definition Format & Field length Interpretation Assistance Indicator Indication of requirement for assistance to communicate in English 2 characters 2.1.4. Socio-Environmental Details Table 6 - Socio-Environmental Details Data Item Definition Format & Field length 9 All data items (unless marked with a ) in the table above are existing nationally approved Generic Data Standards for health and/ or social care. They are published in the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk which contains further information such as data categories and recording guidance. 10 It is recommended that Address (BS7666), which is a structured address, should be used in all new IT systems. 11 UK Government Data Standards Catalogue website http://www.govtalk.gov.uk/gdsc/html/frames/default.htm Mental Health Datasets Page 14

Employment Status Household Composition Lives With Accommodation Type Person Legal Status Indicates the person s economic position in the labour market in terms of whether he or she is currently employed in paid work, seeking employment or, either by choice or age or other restriction, not economically active. This item indicates the make-up and structure of the person s household. An indicator to identify the person/ client's domestic circumstances. The type of accommodation in which the service user is normally resident. A particular status usually sanctioned by the courts or by the children's hearing system in relation to the client/patient in order to ensure their protection and/or the protection of others. 3 characters 3 characters 2 characters Up to 6 characters (2 + 4) 3 characters 2.1.5. Background Health Information Table 7 Background Health Information Data Item Definition Format & Field length Impairment An indicator of whether the client/patient has any impairment, which may affect the ability of professionals to communicate with the client/patient, or may impact on the assessment process or the delivery of services. 2 characters 2.1.6. Associated Person Details 12 Common name: Other person Definition: People who have a significant involvement or relationship with the patient/ client (e.g. main carer, next of kin, key holder, emergency contact, etc). This includes professionals who are not involved in the care of the patient/ client e.g. accountant, lawyer. Further information: Where an associated person s age is of relevance to the patient/ client s care e.g. where the associated person is a child or an elderly person, it is recommended that their date of birth be recorded. The full or precise birth date may not be required e.g. the birth year may suffice. Where necessary a derived age may be calculated. Personal information about a third party should be recorded with their knowledge and consent. Recording guidance: Data about multiple associated persons may need to be recorded. Where a patient/ client has an associated person not fulfilling a specific role, e.g. other household members, IT systems should allow for an entry of none. Data can be entered for all people significantly associated with the person, including all members of the person s household. Table 8 - Associated Person Details Table 12 All data items (unless marked with a ) in the table above are existing nationally approved Generic Data Standards for health and/ or social care. They are published in the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk which contains further information such as data categories and recording guidance. Mental Health Datasets Page 15

Data Item Definition Format & Field length Associated Person Full Name 70 characters (unstructured) Associated Person Structured Name 13 - Associated Person Family Name - Associated Person Given Name - Associated Person Preferred Forename Person Birth Date Associated Person Address 14 (BS7666) Associated Person Postcode Associated Person Telephone Number Associated Person Internet Email Address Associated Person Current Gender Associated Person Role This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. An ordered sequence of person name elements such as title, forename(s) and family name. The date on which a person was born or is officially deemed to have been born. A collection of data describing the addressing of locations The code allocated by the Post Office to identify a group of postal delivery points. A minimum standard is provided for holding a UK STD code. An extended set of component parts is provided for systems to hold more information. The string of characters that identifies an addressee's post box on the internet. A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned). The particular involvement(s)/ relationship(s) of each associated person is (are) indicated by the "Person Role" data item. Data should be entered for all people significantly associated with the subject, including members of his/her household. The relationship of an Associated Person to the client/patient. 35 characters 10 characters (CCYY- MM-DD) see Government Data Standards Catalogue Website 15 8 characters 35 characters per element 255 characters 1 character 3 characters Associated Person Relationship to 3 characters Client/Patient Data Item Definition Format & Field length Comments about Associated For consultation see section 3 Person Age of Associated person (if a 2 characters child) 2.1.7. General Medical Practitioner Details 16 Common name: Specified GP 13 It is recommended that Structured Name should be used in all new IT systems. Person Full Name (Unstructured) should only be used in legacy systems, which should migrate to use of Structured Name in due course. 14 It is recommended that Address (BS7666), which is a structured address, should be used in all new IT systems. 15 UK Government Data Standards Catalogue website http://www.govtalk.gov.uk/gdsc/html/frames/default.htm 16 All data items (unless marked with a ) in the table above are existing nationally approved Generic Data Standards for health and/ or social care. They are published in the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk which contains further information such as data categories and recording guidance. Mental Health Datasets Page 16

Definition: A doctor who has a certificate of satisfactory completion of GP training or equivalent. The specified GP is an individual GP within the patient/client s registered practice who needs to be identified for a particular role they fulfil. N/A Further information: Commencing April 2005, patients are registered with a GP practice, not with an individual GP. The registered GP practice code is the primary identifier for this purpose. The details of the individual GPs working within a practice are recorded against the GP practice code. There may be an individual GP within the practice who fulfils a specific purpose, e.g. patients may have a GP whom they prefer to provide their care where possible. The GP role data standard should be used to identify these roles. The reason for having the GP standard is based on the assumption that there will still be a need to contact the GP who is involved with a patient s health and primary care provision even though patients are registered with a practice rather than a GP. Table 9 - General Medical Practitioner Details Table Data Item Definition Format & Field length GP General Medical Council The General Medical Council (GMC) 8 characters Number number is the personal identification number issued to each medical doctor by the General Medical Council. Registered GP Practice Code Each GP practice in Scotland is 6 characters identified by a unique GP practice code. Full Name (unstructured) This alternative to recording structured name involves the whole name being recorded as a single character string with no separately 70 characters Structured Name 17 - Family Name - Given Name - Preferred Forename identified elements. An ordered sequence of person name elements such as title, forename(s) and family name. 35 characters 17 It is recommended that Structured Name should be used in all new IT systems. Person Full Name (Unstructured) should only be used in legacy systems, which should migrate to use of Structured Name in due course. Mental Health Datasets Page 17

Table 9 - General Medical Practitioner Details Table continued Data Item Definition Format & Field length Professional Address 18 (BS7666) A collection of data describing the addressing of locations see Government Data Standards Catalogue Website 19 Postcode The code allocated by the Post Office 8 characters to identify a group of postal delivery points. UK Telephone Number A minimum standard is provided for holding a UK STD code. An extended set of component parts is provided for systems to hold more information. 35 characters per element Internet Email Address Specified GP Role General Practice Registration Status of Patient The string of characters that identifies an addressee's post box on the internet. The function carried out by an individual GP in relation to the patient/client, who may or may not be within the patient/client's registered practice. The registration status of the patient with the general practice from which they are receiving care 255 characters 2 characters 3 characters 2.1.8. Associated Professional Details 20 Common name: Associated Care Professional, Care Professional Definition: Associated Professionals are those individuals who are involved with the patient/ client in a professional capacity e.g. consultant, social worker, occupational therapist, etc. Related data items: see Associated Professional Table Further information: Involvement includes contacts in relation to a particular episode of care. Table 10 - Associated Professional Details Data Item Definition Format & Field length Associated Professional Identifier The unique identifier issued to all 8 characters health and social care professionals by their professional regulatory body. Full Name (unstructured) This alternative to recording 70 characters structured name involves the whole name being recorded as a single character string with no separately identified elements. Data Item Definition Format & Field length Structured Name 17 An ordered sequence of person 35 characters per element - Person Family Name name elements such as title, - Person Given Name forename(s) and family name. - Person Preferred Forename 18 It is recommended that Address (BS7666), which is a structured address, should be used in all new IT systems. 19 UK Government Data Standards Catalogue website http://www.govtalk.gov.uk/gdsc/html/frames/default.htm 20 All data items (unless marked with a ) in the table above are existing nationally approved Generic Data Standards for health and/ or social care. They are published in the Health and Social Care Data Dictionary www.datadictionary.scot.nhs.uk which contains further information such as data categories and recording guidance. Mental Health Datasets Page 18