MHEDD Data Collection Tool
This form is to be used to collect information for patients of all ages presenting with a primary MH complaint to the
ED. This will be used predominantly by MH clinicians but can be used by ED staff where mental health staff are not
contacted.
If used for retrospective data collection it can be used for patients with a MH DRG and/or those that were referred
to MH for assessment. Refer to the reverse for codes where required.
CLINICIAN NAME:
A) PATIENT MRN:
B) SEX:
C) AGE IN YEARS:
D) DATE OF PRESENTATION: DD/MM/YYYY
E) DAY OF THE WEEK: (circle)
F) MODE OF PRESENTATION:
Mo / Tu / We / Th / Fr / Sa / Su
G) TRIAGE DATE & TIME: DD/MM/YY HRS:MINS
H) TIME S/B ED MO: HRS:MINS
I)TIME REFERRED TO MH:HRS:MINS
J) TIME FIRST S/B MH: HRS:MINS
K) TIME 2ND SEEN BY MH: HRS:MINS
L) TIME MH DECISION: HRS:MINS
M) ATRS: (1-5)
N) MODE OF ASSESSMENT: (See reverse)
P) DATE & TIME OF DEPARTURE: DD/MM/YYYY HRS:MINS
O) MH DECISION: (See reverse)
Q) TOTAL TIME IN ED:
R) BREACH: YES / NO
HRS:MINS
S) LEGAL STATUS ON DEPARTURE:
(See reverse)
T) REFERRED TO: (See reverse)
V) PROVISIONAL DIAGNOSIS BY MH CLINICIAN: CODE
(See reverse: do not use F99 unless there is no
alternative)
U) DEPARTURE DIAGNOSIS: PRIMARY DRG AS
CODED IF KNOWN.
W) SECONDARY DIAGNOSIS BY MH CLINICIAN: CODE
(See reverse: do not use F99 unless there is no
alternative)
X-AH)REASONS FOR DELAY: TICK ALL THAT APPLY
Medical complexity requiring acute medical care i.e. toxicology
Delay in referral (more than 60 minutes post triage)
Delay in MH Assessment (more than 60 minutes post referral)
Delay in MH consulting with Senior MH clinician
Intoxicated Alcohol (unable to assess)
Intoxicated Drugs (or suspected drug affected and unable to assess)
Acute Behavioural Disturbance requiring sedation
No MH bed available
Unable to admit after hours
Unsafe to discharge after hours
Transport to another facility
FURTHER INFORMATION OR COMMENTS:
F) Mode of presentation
1 -Self
2 -Community MHT
3 -Ambulance
4 -Police
5 -GP initiated
6 -Other, clarify in comments
N) Mode of Assessment
1 -Face to Face
2 -Video link
3 -Telephone
4 –Other, clarify in comments
O) MH Decision
1 -Admit MH
2 -Admit other, clarify in comments
3 -Transfer MH
4 -Discharge
S) Legal Status
1 -Vol
2 -Invol - MD
3 -Invol - MI
4 –NA (to be used if discharged)
T) Referred to
1 -GP only
2 -D&A service
3 -Psychology - NSW Health
4 -CMHT
5 -Other MH Service
6 -CMO/NGO
7 -Not applicable
V, W) Provisional Diagnosis
R45.8 Suicidal Ideation
X60-X84 Suicide attempt (various means)
F01 Vascular dementia
F03 Unspecified dementia
F05 Delirium due to known physiological condition
F10.0 Mental & Beh Disorder Alcohol related
F11 Mental & Beh Disorder Opioid related
F12 Mental & Beh Disorder Cannabis related
F13 Mental & Beh Disorder Sedative, hypnotic, or
anxiolytic related
F14 Mental & Beh Disorder Cocaine related
F15 Mental & Beh Disorder Other stimulant related Amphetamines
F16 Mental & Beh Disorder Hallucinogen related
F18 Mental & Beh Disorder Inhalant related
F19 Mental & Beh Disorder Other psychoactive
substance related - Polysubstance
F20.0 Paranoid Schizophrenia
F22 Delusional disorders
F23 Brief psychotic disorder
F25 Schizoaffective disorders
F29 Unspecified psychosis not due to a substance or
known physiological condition
F30 Manic episode
F31 Bipolar disorder
F32 Major depressive disorder, single episode
F33 Major depressive disorder, recurrent
F43 Reaction to severe stress, and adjustment disorders
F50 Eating disorders
F53 Puerperal psychosis
F60.2 Antisocial personality disorder
F60.3 Borderline personality disorder
F60.8 Other specific personality disorders
F63 Impulse disorders
F79 Unspecified intellectual disabilities
F84 Pervasive developmental disorders
F88 Other disorders of psychological development
F90 Attention-deficit hyperactivity disorders
F91 Conduct disorders
F93 Emotional disorders with onset specific to childhood
F94 Disorders of social functioning i/c onset specific to
childhood and adolescence
F98 Other behavioural & emotional disorder with onset
usually occurring in childhood and adolescence
F99 Mental disorder, not otherwise specified