OP MH Depression Dataset
OP MH Depression Data Manual
National Mental Health Dataset Project
OP MH Depression Data Manual
Based on OP MH Depression Dataset Draft Version 1.3
Draft Version 0.2
March 2005
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OP MH Depression Dataset
OP MH Depression Data Manual
Distribution
Author
Further copies
from
Date of issue
Draft Version 0.2
March 2005
2
On request
Jimmy Bates
Penny Bray
NHS Information Authority
Kings Court
The Broadway
Winchester, SO23 9BE
Tel: 0121 333 0333
E-mail: penny.bray@nhsia.nhs.uk
March 2005
OP MH Depression Dataset
OP MH Depression Data Manual
Table of Contents
A
Introduction
B
Guide to Data Collection
1
2
3
4
5
6
7
8
C
Person Demographics
Depression Needs Assessment
Depression & Morale Assessment and Clinical Diagnosis
Depression and Screening for other potential issues
Medication Review & Antidepressant Drug Therapy
Referral to Specialist & Referral to Specialist Treatments and Therapies
Patient and Doctor’s perception of the patient’s progress and condition
Access to Other Services/Facilities
Appendices
a
b
c
Key – List of Abbreviations
Clinical Codes
References
List of Tables
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Full List of Business Requirements
Data Items: Person Demographics
Business Requirements Linked to
Depression Needs Assessment Data Items
Data Items: Depression Needs Assessment
Business Requirements Linked to
Depression & Morale Assessment and Clinical Diagnosis Data Items
Data Items: Depression & Morale Assessment and Clinical Diagnosis
Business Requirements Linked to Depression and Screening for other potential issues Data Items
Data Items: Depression and Screening for other potential issues
Business Requirements Linked to Medication Review & Antidepressant Drug Therapy Data Items
Data Items: Medication Review & Antidepressant Drug Therapy
Business Requirements Linked to Referral to Specialist & Referral to Specialist Treatments and
Therapies Data Items
Data Items: Referral to Specialist & Referral to Specialist Treatments and Therapies
Business Requirements Linked to Patient and Doctor’s perception of the patients progress and condition
Data Items
Data Items: Patient and Doctor’s perception of the patients progress and condition
Business Requirements Linked to Access to Other Services/Facilities Data Items
Data Items: Access to Other Services/Facilities
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OP MH Depression Data Manual
Introduction
Background
The Depression dataset is one of five datasets to support the implementation of the National Service Framework
(NSF) for Older People and has been produced by a multi-professional working group (WG) during 2004.
NSF Standard seven: mental health in old people covers both depression and dementia (dementia is the subject
of a separate, but related dataset). The aim of this standard is:
“To promote good mental health in older people and to treat and support those older people with dementia and
depression”
Standard seven itself states “Older people who have mental health problems have access to integrated mental
health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support, for them
and their carers.
Mental health problems among older people exact a large social and economic toll on patients, their families and
carers, and the statutory agencies. Under-detection of mental illness in older people is widespread, due to the
nature of the symptoms and the fact that many older people live alone. Older people from black and minority
ethnic communities need accessible and appropriate mental health services, which may not currently be readily
accessible or fully appropriate - leading to distrust of agencies tasked with providing this support. Older people
with mental health disabilities may also have difficulties obtaining appropriate mental health care.
Although the focus tends to be on depression and dementia, which are particularly common in older people,
illnesses such as schizophrenia also occur. In developing these two datasets (depression and dementia), the
working group (WG) recognised that mental health problems can affect people of any age, but that mental health
problems tend to increase by age. The WG took the view that much of the data will be collected in a primary
care and community setting, with GPs, practice and community nurses being prime examples of professional
staff users of these datasets. That being said, it is recognised that many other professional staff will be involved
at various stages, including for example: consultants, psychiatrists, pharmacists, therapists, etc.
The data items were generated from a set of related business requirements that were derived mainly from the
Older People NSF, the GMS contract and guidelines from the National Institute of Clinical Effectiveness
(NICE). This was complemented with NHS performance indicators and specialist advice from members of the
Mental Health WG itself. The business requirements were compiled to identify a concise set of particular
national and local information imperatives to enable depression dataset development, so that the monitoring of
best practice in depression care can be monitored.
Purpose of this document
The purpose of this document is to provide additional information in support of the depression dataset. It
functions as a reference guide for any health and care professional who comes into contact with older people.
There are 15 major business requirements that will be met with the completion of the depression dataset – each
one linked back to expert opinion or policy (or similar) guidance. The business requirements are listed in table 1
(page 8) – the origins of each one being outlined more fully in the relevant section. Developing a list of business
requirements was a precursor to the development of the dataset: the WG defined what questions need to be
answered through the business requirements and subsequently listed data items to meet these requirements.
A summary of good practice for the provision of integrated mental health services can be seen in the National
Service Framework for Older People, Chapter 2:
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/OlderPeoplesServices/fs/en
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Key Issues around Using the Depression Dataset:
Use of the dataset is intended to help improve the prevention, care and treatment of mental health problems in
old ages through:

promoting good mental health

early recognition and management of mental health problems

access to specialist care
The dataset is designed as a proactive approach for health and care professionals to begin entering depression
data from the date when a depression assessment is carried out (as a routine for over 75 year olds), through
diagnosis, screening, referral, progress and subsequent support, building up a long-term record of individual
depression histories.
The depression dataset is intended to be used for all patients identified as having a depression issue.
The dataset covers all stages of the provision of integrated mental health services across the primary, secondary
and residential care sectors. Each care provider will be responsible for collecting the required information
relating to their contact with the patient, although demographic information will be supplemented by
administrative data. The development and implementation of this dataset is a significant undertaking for all
those involved in the management and delivery of mental health care.
Finally, it should be noted that the first section of the dataset, Person Demographics, is common to all Older
People (and other) Datasets. This section has been designed to be consistent in format with the NHS Data
Dictionary, the National Programme for Information Technology (NPfIT), NHS Information Authority standards
and the Single Assessment Process (SAP). For those items subject to NHS Data Dictionary format, this is not
defined in the dataset itself; rather, reference is made to the data dictionary as the source of information (which is
only accessible online, because it is subject to continual update). Access to the NHS Data Dictionary is via:
www.nhsia.nhs.uk/datastandards/pages/ddm/index.asp
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How to use this guide
The data items are grouped into 7 sections:
1.
2.
3.
4.
5.
6.
7.
Person Demographics*
Depression & Morale Assessment and Clinical Diagnosis
Depression and Screening for other potential issues
Medication Review & Antidepressant Drug Therapy
Referral to Specialist & Referral to Specialist Treatments and Therapies
Patient and Doctor’s Perception of the Patient’s Progress and Condition
Access to Other Services and Facilities
* This section has been designed to be consistent in format with the NHS Data Dictionary, the National
Programme for Information Technology (NPfIT), NHS Information Authority standards and the Single
Assessment Process (SAP) for older people.
For each of the other main sections there is a brief text introduction, followed by a table listing the relevant
business requirements for that particular section, eg:
No.
8.
Business Requirement
Referral to specialist team for severe depression
should be considered
Document of Origin
Clinical guidelines
Comment
Therapies to be taken
from the MHMDS
interventions document
The ‘document of origin’ indicates where the main influence came from for the inclusion of the business
requirement. The business requirement may not always be a straight quote and may differ slightly as the
working group strove to balance the requirements of a number of documents and make the statements relevant to
the dataset development. Where the business requirement was the result of expert opinion from the working
group (or external reference group) it is indicated in this column.
The ‘Comment’ column contains additional detail about the data that must be collected for each item.
Each section then follows with a second table which lists the data items (from the dataset itself) for the section,
eg:
No.
2.1
Data Item
Date of last
routine
health check
Description
The date of the last routine
health check
Purpose
Routine health checks should screen for
depression
The first column is the number of the data item, the second is the title of the data item, the third is a description
of the item and the fourth explains the purpose of collecting this data item (the format in which the data should
be collected is described in the following sections of this manual).
If the data item is defined to conform to another existing dataset (eg, Single Assessment Summary dataset), this
is also indicated in this column.
The fourth (‘Purpose’) column also includes a reference to the related business requirement that it is designed to
meet (in full or part).
A final column contained in the actual dataset itself provides a description of the format the required data is to be
collected in.. These required formats are individually described in this manual immediately following each
table.
The appendices of this manual contain a list of clinical codes related to relevant data items, plus a listing of the
abbreviations and references used in the depression dataset.
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Table 1
Ref
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
OP MH Depression Data Manual
Full List of Mental Health Business Requirements
Business Requirement
Targeted screening in primary care for the prevention of depression in the elderly
should take place. Key risk factors are: recent major physical illness (the last 3
months) chronic disabling illness, receiving high level of home support (personal care)
Screening for depression be included in the over 75 check
Depression starting late in life may be a predictor of dementia. Older patients
presenting with depression for the first time should be screened for dementia
Proportion of GP patients diagnosed with depression who have a record in their notes
of being asked about suicidal intent
There should be evidence that a full clinical evaluation has taken place according to
local protocol
Patient's full range of medication reviewed at home visit and medication needs support
assessed
Newer anti depressant drugs should be used
All patients’ antipsychotics or benzodiazepines +/- 4 or more drugs should be reviewed
every 6 months.
Referral to specialist team for severe depression should be considered
all patients should have fair and equal access to recognised non pharmacological
interventions for depression (primary care)
all patients should have fair and equal access to recognised interventions for depression
(secondary care)
Patients referred for specialist assessment and treatment should have access to a multiprofessional team, including Social Services (as multi-professional does not mean multi
agency, as it would per dementia data requirements)
Patients undergoing treatment for depression should undergo regular review:
appropriate to their condition
Both the patient's and Doctor's perception of the patient's progress should be recorded
at each review
There should be access to inpatient and day treatment facilities if required
Intermediate care (emergency and planned), and 24 hour access to crisis support
services should be available to patients and carers
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B
Guide to Data Collection
1
Person Demographics
This section is common to all datasets and contains data items that provide information about the person. These
data items are listed here together for reference, but it is not intended that they should necessarily all be collected
at the same point in the pathway. Rather, some should be collected once, on initial contact with the person;
others should be collected at each point during the course of treatment.
Where this information is exchanged, the appropriate data item name should be used to identify the particular
instance of the data.
Some data items for a person will never change; others can and will change over time.
As noted in the ‘How to Use this Guide’ section above, those data items already published in the NHS
Dictionary contain only an associated reference to the data dictionary in the ‘Description’ column (rather than an
actual description of the item, because it is which subject to continuous update). Likewise, this same reference is
all that is contained in the ‘Codes and Classifications’ column for these same data items (rather than a definition
of the format in which the data for these items is to be collected) for the same reason. Access to the NHS Data
Dictionary can only be made online (rather than being able to obtain a paper or electronic disk-based copy), to
ensure that professional users of the dataset are always provided with the latest up-to-date version.
Table 2
Ref.
Data Items: Person Demographics
Data Item
Description
Purpose
1.1
NHS NUMBER
See NHS Data Dictionary
1.2
LOCAL PATIENT
IDENTIFIER
ORGANISATION
CODE (LOCAL
PATIENT
IDENTIFIER)
CASE NUMBER
See NHS Data Dictionary
Used to uniquely identify the patient who is the
subject of the dataset.
Used to uniquely identify the patient within a
health care provider
No.
1.2a
1.3
1.3a
1.4
1.5
1.8
1.9
1.6
1.7
LOCAL
AUTHORITY
CODE
PERSON FAMILY
NAME
PERSON GIVEN
NAME
PATIENT USUAL
ADDRESS
POSTCODE OF
USUAL
ADDRESS
PRESENT
ADDRESS
POSTCODE OF
PRESENT
ADDRESS
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See NHS Data Dictionary
The unique number assigned to a
person when they are formally
recognised as a social service user and
have a case opened for them.
The identifier of a local authority
within the UK
Used to uniquely identify the patient who is the
subject of the Dataset within a local authority care
provider
See NHS Data Dictionary
Identifies that part of a person's name that is used
to describe family, clan, tribal group, or marital
association.
Identifies the forename or given name of a person.
See NHS Data Dictionary
See NHS Data Dictionary
Identifies the address details for the person at their
usual address
See NHS Data Dictionary.
This is the ADDRESS nominated by
the PATIENT, with ADDRESS
ASSOCIATION TYPE of Present
address’
The POSTCODE of the ADDRESS
nominated by the PATIENT with
ADDRESS ASSOCIATION TYPE
'Present Address’.
8
Identifies the address details for the person at their
present address where this is different from their
usual address
OP MH Depression Dataset
Ref.
OP MH Depression Data Manual
Data Item
Description
Purpose
1.10
PERSON BIRTH
DATE
See NHS Data Dictionary
1.11
PERSON
GENDER
CURRENT
ETHNIC
CATEGORY
See NHS Data Dictionary
Additional identifier for the person who is the
subject of the dataset. Also required for the
calculation of age. To enable the provision of case
mix indicators.
Identifies the phenotypical gender classification
that currently applies to the person.
No.
1.12
1.13
1.14
1.14a
1.15
1.16
1.17
1.18
1.1
GP NAME
(NAME OF
REGISTERED OR
REFERRING
GMP)
GMP (CODE OF
REGISTERED OR
REFERRING
GMP)
ORGANISATION
NAME (GP
PRACTICE)
CODE OF GP
PRACTICE
(REGISTERED
GMP)
ORGANISATION
CODE (PCT OF
GP PRACTICE)
ORGANISATION
CODE (CODE OF
PROVIDER)
ORGANISATION
CODE (CODE OF
COMMISSIONER)
See NHS Data Dictionary.
Records the ethnicity of a person, as specified by
the person.
See NHS Data Dictionary
Identifies the name of the person’s general
medical practitioner
See NHS Data Dictionary.
Identifies the unique code for the person’s general
medical practitioner
The name of the GP practice for the
GMP who has either registered or
referred the PATIENT
See NHS Data Dictionary
Identifies the name for the person’s general
medical practitioner
See NHS Data Dictionary
Identifies the unique code of the Primary Care
Trust responsible for the GP practise at which the
person is registered.
Identifies the unique code of the
ORGANISATION providing the care to the
patient.
Identifies the unique code of the
ORGANISATION commissioning the care for the
patient.
See NHS Data Dictionary
See NHS Data Dictionary
Identifies the unique practise code for the person’s
general medical practitioner
NHS Number
Record the person’s unique NHS Number. It is mandatory to record the new NHS number for each person. If
the NHS number is not available for a person it can be accessed via the NHS Tracing Service. Access to the
NSTS is via the secure website at http://nww.nhsia.nhs.uk/nsts
This can take some time but need only be done once for each person and then the information shared as this is a
permanent lifetime number that will not change.
 Format is as defined in the NHS Data Dictionary
1.2
Local Patient Identifier
Record the code used specifically within the organisation to uniquely identify the patient. This may be hospital
site specific, that is, there may be different hospital numbers collected for the person at different points in the
pathway – hence the data item should be a repeating item.
 Format is as defined in the NHS Data Dictionary
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1.2a Organisation Code (Local Patient Identifier)
Record the code used specifically to identify the organisation responsible for the care or treatment of the patient.
The patient may be treated at more than one organisation hence this will need to be a repeating data item.
 Format is 5 alphanumeric characters
1.3
Case Number
Social services case number to allow identification of person records held by social services. NHS number
should be the primary identifier for all persons.
 Up to 10 alphanumeric characters are allowed.
1.3a Local Authority Code
This data item is used in conjunction with the previous one (Case Number) to provide a unique reference for the
person. This pair of data items may occur any number of times.
The organisation identifier of the local authority providing social care to the person:
 Format is an4, comprising 2 numeric characters followed by 2 alphabetical characters
1.4
Person Family Name
Identifies that part of a person’s name which is used to describe the family, clan, tribal group or marital
association who is the subject of the Depression Dataset. If the person’s family name (surname) changes during
care, it is essential that the latest name is recorded.
 Format is as defined in the NHS Data Dictionary
1.5
Person Given Name
Identifies the forename or given name of the person who is the subject of the Depression Dataset. If the person’s
forename(s) or personal name(s) changes during care, it is essential that the latest names are recorded
 Format is as defined in the NHS Data Dictionary
1.6
Patient Usual Address
Identifies the address details for the person at their usual address.
 Format is as defined in the NHS Data Dictionary
1.7
Postcode Of Usual Address
Identifies the address details for the person at their usual address.
 Format is as defined in the NHS Data Dictionary
1.8
Present Address
Identifies the address details for the person at their present address where this is different from their usual
address.
 Format is the same as defined in the NHS Data Dictionary for PATIENT USUAL ADDRESS
1.9
Postcode of Present Address
Identifies the address details for the person at their present address where this is different from their usual
address.
 Format is the same as defined in the NHS Data Dictionary for PATIENT USUAL ADDRESS
1.10
Person Birth Date
This is an additional identified for the person who is subject to the dataset. It is also required to calculate the
person’s age, and to enable the provision of case mix indicators.
 Format is as defined in the NHS Data Dictionary
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1.11
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Person Gender Current
Identifies the phenotypical gender classification that currently applies to the person
 Format is as defined in the NHS Data Dictionary
1.12
Ethnic Category
Records the ethnicity of a person, as specified by the person.
 Format is as defined in the NHS Data Dictionary
1.13
GP Name (Name of Registered or Referring GMP)
Identifies the name of the person’s general medical practitioner.
 Format is as defined in the NHS Data Dictionary
1.14
GMP (Code Of Registered Or Referring GMP)
Identifies the unique code for the person’s general medical practitioner
 Format is as defined in the NHS Data Dictionary
1.14a Organisation Name (GP Practice)
Identifies the name for the person’s general medical practitioner.
 Format is a maximum of 255 alphanumeric characters
1.15
Code of GP Practice (Registered GMP)
Identifies the unique practice code for the person’s general medical practitioner.
 Format is as defined in the NHS Data Dictionary
1.16
Organisation Code (PCT of GP Practice)
Identifies the unique code of the Primary Care Trust responsible for the GP practice at which the person is
registered
 Format is as defined in the NHS Data Dictionary
1.17
Organisation Code (Code of Provider)
Identifies the unique code of the ORGANISATION providing care to the patient.
 Format is as defined in the NHS Data Dictionary
1.18
Organisation Code (Code of Commissioner)
Identifies the unique code of the ORGANISATION commissioning the care for the patient.
 Format is as defined in the NHS Data Dictionary
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Depression Needs Assessment
Data items 2.1 to 2.4 relate to information about the initial assessment of depression, the role of the healthcare
individual who collected the information, and related dates. They originate from a number of business
requirements (see below) and can be referenced back primarily to the Single Assessment Process (SAP), clinical
guidelines and expert opinion from the mental health dataset WG.
Table 3
Business Requirements Linked to Depression Needs Assessment Data Items
Ref
Business Requirement
1.
Screening for depression should be
included in the over 75 check
Document of
Origin
SAP
Comment
NICE guidelines
Table 4
Data Items: Depression Needs Assessment
Data Item
2.1
2.2
2.3
DATE OF LAST
ROUTINE HEALTH
CHECK
DATE OF NEEDS
ASSESSMENT
(DEPRESSION)
ASSESSMENT
(DEPRESSION &
MORALE)
Description
Purpose
The date of the last routine health
check
Routine health checks should screen for
depression
The date the memory assessment was
conducted
Business Requirements Draft v0.8
Requirement 2
Business Requirements Draft 0.8
Requirement 2
A summary of the person’s needs and
circumstances related to their
depression captured within a Single
Assessment Process
The person responsible for the
depression needs and circumstances
assessment
2.4
NEEDS ASSESSOR
2.1
Date of last Routine Health Check
The date of the last routine health check.
 Format is 8 numeric characters (with 2 spaces) indicating the year-month-day (4-2-2)
2.2
Date of Needs Assessment (Depression)
The date the memory assessment was conducted
 Format is 8 numeric characters (with 2 spaces) indicating the year-month-day (4-2-2)
2.3
Assessment (Depression & Morale)
A summary of the person’s needs and circumstances related to their depression captured within a Single
Assessment Process.
 Format is 2 numeric characters (to indicate Need being addressed, not being addressed, No current need or
Unknown)
2.4
Needs Assessor
The person responsible for the depression and circumstances assessment:
 Format is text
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Depression & Morale Assessment and Clinical Diagnosis
Data items 3.1 to 3.12 relate to detailed assessment of depression and morale, including scale used and score,
diagnosis and related dates. They originate from a number of business requirements (see below) and can be
referenced back to the National Service Framework for Older People, SAP, clinical guidelines and expert
opinion from the depression dataset WG.
Table 5
Business Requirements Linked To Depression & Morale Assessment and
Clinical Diagnosis
Ref
Business Requirement
1
Targeted screening in primary care
for the prevention of depression in the
elderly should take place. Key risk
factors are: recent major physical
illness (the last 3 months), chronic
disabling illness, receiving high level
of home support (personal care)
Table 6
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Comment
NICE guidelines
Data Items: Depression & Morale Assessment and Clinical Diagnosis
Data Item
3.1
Document of
Origin
SAP
ASSESSMENT
DATE
(DEPRESSION &
MORALE)
ASSESSMENT
SCALE USED
(DEPRESSION &
MORALE)
ASSESSMENT
SCORE
(DEPRESSION &
MORALE)
PHYSICAL
DISABILITY
DIAGNOSIS
(ENDURING
IMPACT ON
NEEDS ICD)
DIAGNOSIS
(ENDURING
IMPACT ON
NEEDS Read)
DIAGNOSIS
(ENDURING
IMPACT ON
NEEDS Snomed)
DIAGNOSIS DATE
(DEPRESSION)
ASSESSMENT
TOOL (SINGLE
ASSESSMENT
PROCESS)
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Description
The date on which the depression and
morale of the person were assessed
using the identified assessment scale
The assessment scale used to determine
the person’s depression and morale
The assessment score achieved by the
person in relation to any depression and
morale
Purpose
Targeted screening in primary care for
the prevention of depression in the
elderly should take place. Key risk
factors are: recent major physical
illness, (in the last three months),
chronic disabling illness, receiving a
high level of home support (personal
care)
Business Requirements Draft 0.8
Requirement 1
Identifies if the person has a physical
disability that has substantial and long
term adverse effect on their ability to
carry out normal day-to-day activities
A medical diagnosis that potentially
has an enduring impact on the health
and social care needs of the person
A medical diagnosis that potentially
has an enduring impact on the health
and social care needs of the person
A medical diagnosis that potentially
has an enduring impact on the health
and social care needs of the person
The date on which the diagnosis of
depression was made
The assessment tool used during the
Single Assessment Process
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Business Requirements Draft 0.8
Requirement 1
Identifies the assessment tool, if any,
used during overview assessment.
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Data Item
3.10
3.11
3.12
3.1
ASSESSMENT
DATE (DAILY
LIVING
ASSESSMENT)
ASSESSMENT
SCALE USED
(DAILY LIVING
ACTIVITIES)
ASSESSMENT
SCORE (DAILY
LIVING
ACTIVITIES)
Description
The date on which the activities and
instrumental activities of daily living
were assessed using the identified
assessment scale.
The assessment scale used to determine
the person’s needs in relation to
activities and instrumental activities of
daily living
The assessment score achieved by the
person in relation to their needs for
activities and instrumental activities of
daily living
Purpose
Business Requirements Draft 0.8
Requirement 1
Business Requirements Draft 0.8
Requirement 1
Business Requirements Draft 0.8
Requirement 1
Assessment Date (Depression & Morale)
The date on which the depression and morale of the person were assessed
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-2)
3.2
Assessment Scale Used (Depression & Morale)
The assessment scale used to determine the person’s depression and morale.
 Format is 2 alphanumeric characters to indicate assessment scale used
3.3
Assessment Score (Depression & Morale)
The assessment score achieved by the person in relation to any depression and morale.
 Format is alphanumeric
3.4
Physical Disability
Identifies if the person has a physical disability that has substantial and long term adverse affect on their ability
to carry out normal day-to-day activities
 Format is 2 numeric characters (to indicate yes, No, Unknown)
3.5-3.7 Diagnosis (Enduring Impact on Needs)
A medical diagnosis that potentially has an enduring impact on the health and social care needs of the person
 Format is relevant ICD, Read, Snomed code
3.8
Diagnosis Date (Depression)
Date on which the diagnosis of depression was made:
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
3.9
Assessment Tool (Single Assessment Process)
The assessment tool used during the Single Assessment Process.
 Format is 2 alphanumeric characters (to indicate tool used)
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Assessment Date (Daily Living Assessment)
The date on which the activities and instrumental activities of daily living were assessed using the identified
assessment scale
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
3.11
Assessment Scale Used (Daily Living Activities)
The assessment scale used to determine the person’s needs in relation to activities and instrumental activities of
daily living
 Format is 2 alphanumeric characters to indicate assessment scale used
3.12
Assessment Score (Daily Living Activities)
The assessment score achieved by the person in relation to their needs for activities and instrumental activities of
daily living
 Format is alphanumeric
Draft Version 0.2
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OP MH Depression Dataset
4
OP MH Depression Data Manual
Depression and Screening for Other Potential Issues
Data items 4.1 to 4.5 relate to assessment and screening for other issues, plus related dates. They originate from
a number of business requirements (see below) and can be referenced back to the National Service Framework
for Older People, draft NHS performance indicators, clinical guidelines and expert opinion from the mental
health WG.
Table 7
Business Requirements Linked To Depression and Screening for Other
Potential Issues
Ref
Business Requirement
3
4
5
Depression starting late in life may be
a precursor of dementia. Older
patients presenting with depression
for the first time should be screened
for dementia
Proportion of GP patients diagnosed
with depression who have a record in
their notes of being asked about
suicidal intent
There should be evidence that a full
clinical evaluation has taken place
according to local protocol
Table 8
4.1
4.2
Comment
Draft NHS
performance
indicators
NICE clinical
guidelines
Data Items: Depression and Screening for Other Potential Issues
Data Item
Description
DIAGNOSIS DATE
(OTHER ISSUES)
The start date on which the diagnosis
of depression was made
Monitor start date of diagnosis against
screening for other issues (see below)
A summary of the person’s memory
loss needs and circumstances
captured within a Single Assessment
Process
Business Requirements Draft 0.8
Requirement 3
Depression starting later in life may be a
predictor of dementia. Older patients
presenting with depression for the first
time should be screened for dementia
ASSESSMENT
(MEMORY LOSS)
4.3
NEEDS ASSESSOR
(MEMORY LOSS)
4.4
CONSULTATION
DATE (SUICIDE
INTENT)
4.5
Document of
Origin
NICE clinical
guidelines
DATE (LAST FULL
CLINICAL
EXAMINATION)
The person responsible for the
memory loss needs and
circumstances assessment.
The date the person was screened for
suicide intent
The last date that the person received
a full clinical examination
Purpose
Business Requirements Draft 0.8
Requirement 3
Business Requirements Draft 0.8
Requirement 3
To monitor the proportion of GP
patients diagnosed with depression who
have a record in their notes about being
asked about suicidal intent
Business Requirements Draft 0.8
Requirement 4
To monitor evidence that a full clinical
examination has taken place according
to local protocol
Business Requirements Draft 0.8
Requirement 5
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16
OP MH Depression Dataset
4.1
OP MH Depression Data Manual
Diagnostic Date (Other Issues)
The start date on which the diagnosis of depression was made.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
4.2
Assessment (Memory Loss)
A summary of the person’s memory loss needs and circumstances captured within a Single Assessment Process.
 Format is 2 numeric characters (to indicate Need being addressed, not being addressed, No current need or
Unknown)
4.3
Needs Assessor (Memory Loss)
The person responsible for the memory loss needs and circumstances assessment.
 Format is text
4.4
Consultation Date (Suicide Intent)
The date the person was screened for suicide intent.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
4.5
Date (Last Full Clinical Examination)
The last date that the person received a full clinical examination.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
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OP MH Depression Dataset
5
OP MH Depression Data Manual
Medication Review & Antidepressant Drug Therapy
Data items 5.1 to 5.19 relate to medication reviews, care plan, prescribing source and related dates. They
originate from a number of business requirements (see below) and can be referenced back to the National
Service Framework for Older People, NICE clinical guidelines and expert opinion from the mental health WG.
Table 9
Business Requirements Linked To Medication Review & Antidepressant
Drug Therapy
Ref
Business Requirement
Patient’s full range of medication
reviewed at home visit and
medication needs support assessed
Document of
Origin
NSF Medicines
6
Newer antidepressant drugs should be
used
NICE clinical
guidelines
7
All patients on antipsychotics or
benzodiazepines +/- 4 or more drugs
should be reviewed every 6 months
NSF
Table 10
Data Items: Medication Review and Antidepressant Drug Therapy
Data Item
5.1
5.2
5.3
5.4
5.5
Comment
(MEDICATION
REVIEW) LAST
REVIEW DATE
PERSON NAME
(CARE
PROFESSIONAL)
PERSON ROLE IN
ORGANISATION
(CARE
PROFESSIONAL)
ORGANISATION
(CARE
PROFESSIONAL)
DATE (OF HOME
VISIT)
Description
The date that the person’s
medication was last reviewed
with their Doctor
This is the PERSON NAME
where PERSON NAME TYPE
classification is 'Preferred Name'
of the CARE PROFESSIONAL.
NAME FORMAT CODE
indicates whether it is a
PERSON NAME
STRUCTURED or PERSON
NAME UNSTRUCTURED.
This is role in the organisation
performed by the care
professional
The name of the organisation
associated with the care
professional
The date of a home visit when
the person’s medication is
reviewed
Purpose
To monitor evidence that persons with
depression have their prescribed drugs
reviewed regularly
Business Requirements Draft 0.8
Requirement 5
Identifies the contact details for a care
professional involved with the care of
the person
Business Requirements Draft 0.8
Requirement 5
Business Requirements Draft 0.8
Requirement 5
Patient’s full range of medication
reviewed at home and medication needs
support assessed. Monitors compliance
with local protocol
Business Requirements Draft 0.8
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OP MH Depression Dataset
5.6
Data Item
PERSON ROLE IN
ORGANISATION
(CARE
PROFESSIONAL)
OP MH Depression Data Manual
Description
This is role in the organisation
performed by the care
professional who undertook the
home visit
5.7
CARE PLAN
(PHARMACEUTICAL
CARE PLAN)
The care plan as it relates to the
person’s medication
5.8
CARE PLAN AGREED
DATE
DRUG THERAPY
TYPE (First Line)
The date the care plan is agreed
Purpose
Business Requirements Draft 0.8
To collect details re the care plan
related to the person’s medication
Business Requirements Draft 0.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
START DATE
PRESCRIBING
SOURCE
(ANTIDEPRESSANT
DRUG)
DRUG THERAPY
TYPE (second Line)
START DATE
DATE (GENERAL
MEDICATION
REVIEW)
PROFESSIONAL ROLE
IN ORGANISATION
(COMPLETING
MEDICATION
REVIEW)
Draft Version 0.2
March 2005
The type of first line drug
therapy treatment for depression
The start date for the first line
treatment of the antidepressant
drug therapy
The originating source of the
prescription of the antidepressant
drug
The type of second line drug
therapy treatment(s) for
depression
The start date for the second line
treatment(s) of antidepressant
drug therapy
The date that the patient’s
medications were reviewed
This is the professional role in
the organisation of the person
reviewing the patient’s
medications.
19
To monitor types of drugs used as the
first line of treatment for depression in
the elderly. Newer types of
antidepressant drugs should be used
where possible
Business Requirements Draft 0.8
Requirement 6
To monitor efficacy of drug prescribing
in relation to diagnosis of depression
Business Requirements Draft 0.8
Requirement 6
To monitor the prescribing source
patterns for antidepressant drugs
To monitor types of drugs used as the
second line of treatment for depression
in the elderly. Newer types of
antidepressant drugs should be used
where possible
(Possible repeat group)
Business Requirements Draft 0.8
Requirement 6
To monitor efficacy of drug prescribing
in relation to diagnosis of depression
Business Requirements Draft 0.8
Requirement 6
All patients receiving antipsychotics or
benzodiazepines +/- 4 or more drugs
should have their drugs reviewed every
six months. Therefore data collected to
monitor review process in patients with
depression
Business Requirements Draft 0.8
Requirement 7
Identifies contact details for the person
who conducted the medication review
OP MH Depression Dataset
5.16
5.17
5.18
5.19
5.1
Data Item
DATE (END DATE
ANTIDEPRESSANT
DRUG THERAPY)
REASON
(ANTIDEPRESSANTS
STOPPED)
DATE (RE START
DATE
ANTIDEPRESSANTS)
REASON
(ANTIDEPRESSANT)
OP MH Depression Data Manual
Description
The date that the antidepressant
treatment ended.
Purpose
To monitor prescribing of
antidepressants.
The reason why the
antidepressant treatment was
ended.
The date that the antidepressant
treatment was re started.
Business Requirements Draft 0.8
Requirement 7
To monitor prescribing patterns for
antidepressants relevant to
depression/morale assessments
To monitor instances of antidepressant
treatment being restarted
The reason why the
antidepressant treatment was re
started.
To monitor prescribing patterns for
antidepressants relevant to
depression/morale assessments
Last Review Date (Medication Review)
The date that the person’s medication was last reviewed with their doctor.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.2
Person name (Care Professional)
Identifies the contact details for a care professional involved with the care of the person.
 Format is a maximum of 70 alphanumeric characters
5.3
Person Role in Organisation (Care Professional)
This is the role in the organisation performed by the care professional.
 Format is a maximum of 255 alphanumeric characters
5.4
Organisation (Care Professional)
The name of the organisation associated with the care professional.
 Format is a maximum of 255 alphanumeric characters
5.5
Date (of Home Visit)
The date of a home visit when the person’s medication is reviewed
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.6
Person Role in Organisation (Care Professional)
This is the role in the organisation performed by the care professional who undertook the home visit.
 Format is a maximum of 255 alphanumeric characters
5.7
Care Plan (Pharmaceutical Care Plan)
The care plan as it relates to the person’s medication.
 Format is a maximum of 255 alphanumeric characters
5.8
Care Plan Agreed Date
The date the care plan is agreed.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
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OP MH Depression Dataset
5.9
OP MH Depression Data Manual
Drug Therapy Type
The type of first line drug therapy treatment for depression.
 Format is 1 alphabetical character (to indicate type of drug)
5.10
Start Date
The start date for the first line treatment of the antidepressant drug therapy
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.11
Prescribing Source (Antidepressant Drug)
The originating source of the prescription of the antidepressant drug
 Format is 1 alphabetical character (to indicate type of NHS organisation)
5.12
Drug Therapy Type
The type of second line drug therapy treatment(s) for depression
 Format is 1 alphabetical character (to indicate type of treatment)
5.13
Start Date
The start date for the second line treatment(s) of antidepressant drug therapy.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.14
Date (General Medication Review)
The date that the patient’s medications were reviewed.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.15
Professional Role in Organisation (Completing Medication Review)
The professional role in the organisation of the person reviewing the patient’s medications.
 Format is a maximum of 255 alphanumeric characters
5.16
Date (End Date Antidepressant Drug Therapy)
The date that the antidepressant treatment ended.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.17
Reason (Antidepressants Stopped)
The reason why the antidepressant treatment was ended.
 Suggested format is 2 numeric characters (to indicate Patient unable to cooperate, patient refused,
Depression/low morale score indicates withdrawal, Unknown)
5.18
Date (Restart Date Antidepressants)
The date that the antidepressant treatment was restarted.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
5.19
Reason (Antidepressant)
The reason why the antidepressant treatment was restarted.
 Suggested format is 2 numeric characters (to indicate reason)
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OP MH Depression Dataset
6
OP MH Depression Data Manual
Referral to Specialist & Referral to Specialist Treatments and
Therapies
Data items 6.1 to 6.38 relate to referrals, assessments, diagnoses, therapies and related dates. They originate
from a number of business requirements (see below) and can be referenced back to the National Service
Framework for Older People, NICE clinical guidelines and expert opinion from the mental health WG.
Table 11
Business Requirements Linked To Referral to Specialist & Referral to
Specialist Treatments and Therapies
Ref
Business Requirement
8
Referral to specialist team for severe
depression should be considered
9
All patients should have fair and
equal access to recognised nonpharmacological interventions for
depression (primary care)
All patients should have fair and
equal access to recognised
interventions for depression
(secondary care)
Patients referred for specialist
assessment and treatment should have
access to multi-professional team,
including Social Services (as multiprofessional does not mean multiagency, as it would per dementia data
requirements)
10
11
Table 12
Document of
Origin
NICE clinical
guidelines
Comment
Therapies to be taken from the MHMDS
interventions document. Would need to
have space to record a number of therapies?
NICE clinical
guidelines
Data Items: Referral to Specialist & Referral to Specialist Treatment and
Therapies
Data Item
Description
6.1
REFERRED ON? (TO
SPECIALIST MENTAL
HEALTH SERVICE)
To capture whether the person
was referred onto a specialist
mental health service
6.2
REFERRAL SOURCE
Source of referral to specialist
mental health service
6.3
REASON (FOR
REFERRAL)
6.4
DATE (REFERRAL TO
SPECIALIST MENTAL
HEALTH SERVICE)
The reason the person was
referred to the specialist mental
health service
The date a referral was made to a
specialist mental health service
6.5
DATE (SEEN BY
SPECIALIST MENTAL
HEALTH SERVICE)
Draft Version 0.2
March 2005
The date the person was seen by
a specialist mental health service
22
Purpose
To capture those cases who are or who
are not referred on for specialist mental
health services. Referral to a specialist
team should be considered
To provide information on sources of
referral to specialist mental health
service
To monitor referral patterns to mental
health services
Provides data on the time between
referral and first appointment
Business Requirements Draft 0.8
Requirement 8
Business Requirements Draft 0.8
Requirement 8
OP MH Depression Dataset
6.6
Data Item
SERVICE TYPE
6.7
PERSON ROLE IN
ORGANISATION
(FIRST MENTAL
HEALTH SPECIALIST)
6.8
ASSESSMENT DATE
6.9
ASSESSMENT
LOCATION
6.10
DIAGNOSIS ICD
(POST SPECIALIST
ASSESSMENT)
6.11
DIAGNOSIS (Read)
6.12
DIAGNOSIS (Snomed)
6.13
REFERRED ON? (TO
PSYCHOLOGICAL
THERAPIES)
6.14
REASON (FOR
REFERRAL)
6.15
DATE (REFERRAL TO
PSYCHOLOGICAL
THERAPIES)
6.16
6.17
DATE (SEEN BY
PSYCHOLOGICALTH
ERAPIST)
THERAPY TYPE
OP MH Depression Data Manual
Description
The type of specialist mental
health service the person was
referred to.
The professional role of the
person making the first specialist
assessment
Date assessed by other relevant
professional
Location where the other health
professional conducted
assessment
The medical diagnosis code ICD
Format arising from the
assessment by the specialist
service
The medical diagnosis code Read
Format arising from the
assessment by the specialist
service
The medical diagnosis code
Snomed Format arising from the
assessment by the specialist
service
To capture whether the person
was referred onto a specialist
psychological therapies
The reason the person was
referred for psychological
therapies
The date a referral was made for
Psychological therapy
Purpose
Patients referred for specialist
assessment and treatment should have
access to a multi professional team,
including Social Services. (Multi
professional does not mean multi agency
for this data set as it would do for
dementia)
Business Requirements Draft 0.8
Requirement 8
Business Requirements Draft 0.8
Requirement 8
Business Requirements Draft 0.8
Requirement 8
To capture those cases who are or who
are not referred on for specialist
psychological therapies. All patients
should have fair and equal access to
recognised non pharmacological
interventions for depression (primary
care)
Business Requirements Draft 0.8
Requirement 8
To monitor referral patterns to
psychological therapies
Provides data on the time between
referral and first appointment
The date the person was seen by
a psychological therapist
Business Requirements Draft 0.8
Requirement 9
Business Requirements Draft 0.8
Requirement 9
The type of specialist mental
health service the person was
referred to.
To monitor the types of psychological
therapies utilised in a primary care
setting
Business Requirements Draft 0.8
Requirement 9
Draft Version 0.2
March 2005
23
OP MH Depression Dataset
6.18
6.19
6.20
6.21
OP MH Depression Data Manual
Data Item
REFERRED ON? (TO
OTHER THERAPIES)
Description
To capture whether the person
was referred onto another type of
therapy
REASON (FOR
REFERRAL)
DATE (OTHER
THERAPIES)
The reason the person was
referred for other therapies
The date a referral was made for
other types of therapy
Purpose
To capture those cases who are or who
are not referred on for other therapies in
a primary care setting. All patients
should have fair and equal access to
recognised non pharmacological
interventions for depression (primary
care)
To monitor referral patterns to
psychological therapies
Provides data on the time between
referral and first appointment
The date the person was seen by
another type of therapist
Business Requirements Draft 0.8
Requirement 9
Business Requirements Draft 0.8
Requirement 9
DATE (SEEN BY
OTHER THERAPIST)
Secondary Care Referrals
6.22
REFERRED ON? (TO
SPECIALIST MENTAL
HEALTH SERVICE,
SECONDARY CARE)
To capture whether the person
was referred onto a specialist
mental health service at
Secondary care level
6.23
REFERRAL SOURCE
Source of referral to specialist
mental health service (ECT)
6.24
REASON (FOR
REFERRAL)
The reason the person was
referred for ECT therapy
6.25
REFERRAL DATE
(ECT THERAPY)
DATE (START DATE
ECT THERAPY)
REFERRED ON? (TO
PSYCHOLOGICAL
THERAPIES,
SECONDARY CARE)
The date a referral was made for
ECT therapy
The date the ECT therapy was
started
To capture whether the person
was referred onto a
psychological therapies at
Secondary care level
6.28
REFERRAL SOURCE
Source of referral to
psychological therapies
6.29
DATE (REFERRAL TO
PSYCHOLOGICAL
THERAPIES
SECONDARY CARE)
The date a referral was made for
psychological therapy in a
secondary care setting
START DATE (SEEN
BY
PSYCHOLOGICALTH
ERAPIST,
SECONDARY CARE)
The date the person was seen by
a psychological therapist and
therapy therefore started
6.26
6.27
6.30
Draft Version 0.2
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24
To capture those cases who are or who
are not referred on for specialist mental
health services within a secondary care
setting. All patients should have fair and
equal access to recognised interventions
for depression.
Business Requirements Draft 0.8
Requirement 10
To provide information on sources of
referral to specialist mental health
services (ECT) provided in a secondary
care setting
To monitor referral patterns to mental
health services providing ECT in
secondary care
Provides data on the time between
referral and start of ECT therapy.
Business Requirements Draft 0.8
Requirement 10
To capture those cases who are or who
are not referred on for psychological
services within a Secondary Care setting.
All patients should have fair and equal
access to recognised interventions for
depression.
To provide information on sources of
referral to psychological therapies
provided in a secondary care setting
Provides data on the time between
referral and first appointment
Business Requirements Draft 0.8
Requirement 10
Business Requirements Draft 0.8
Requirement 10
OP MH Depression Dataset
6.31
Data Item
THERAPY TYPE
OP MH Depression Data Manual
Description
The type of specialist mental
health service the person was
referred to.
6.32
REFERRED ON? (TO
OTHER THERAPIES,
SECONDARY CARE)
To capture whether the person
was referred onto another type of
therapy
6.33
REASON (FOR
REFERRAL)
DATE (OTHER
THERAPIES)
The reason the person was
referred for other therapies
The date a referral was made for
Other types of therapy
6.34
6.35
DATE (SEEN BY
OTHER THERAPIST)
6.36
THERAPY TYPE
The date the person was seen by
another type of therapist in a
secondary care setting
The type of specialist mental
health service the person was
referred to.
6.37
DATE DISCUSSED
Date on which the case is
discussed at the MDT (Multi
Disciplinary Team)
6.38
REVIEW DATE
Date on which the patient is
reviewed
Purpose
To monitor the types of Psychological
therapies utilised in a secondary care
setting
Business Requirements Draft 0.8
Requirement 10
To capture those cases who are or who
are not referred on for other therapies in
a Secondary Care setting. All patients
should have fair and equal access to
recognised non pharmacological
interventions for depression (secondary
care)
To monitor referral patterns to
psychological therapies
Provides data on the time between
referral and first appointment
Business Requirements Draft 0.8
Requirement 10
Business Requirements Draft 0.8
Requirement 10
To monitor the types of psychological
therapies utilised in a secondary care
setting
Business Requirements Draft 0.8
Requirement 10
Patients referred for specialist
assessment and treatment should have
access to a multi professional team
including social services.
To monitor that patients with depression
are provided regular review as
appropriate to their condition
Business Requirements Draft 0.8
Requirement 11
6.1
Referred On? (to specialist mental health service)
To capture whether the person was referred onto specialist mental health service
 Format is 2 numeric characters (to indicate Yes, No, Unknown)
6.2
Referral Source
Source of referral to specialist mental health service.
 Format is 2 numeric characters to indicate type of organisation
6.3
Reason for Referral
The reason the person was referred to the specialist mental health service
 Format is 2 numeric characters to indicate reason
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25
OP MH Depression Dataset
6.4
OP MH Depression Data Manual
Date (Referral to Specialist Mental Health Service)
The date a referral was made to a specialist mental health service
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.5
Date (Seen by Specialist Mental Health Service)
The date the person was seen by a specialist mental health service
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.6
Service Type
The type of specialist mental health service the person was referred to.
 Format is 2 numeric characters to indicate service type
6.7
Person Role in Organisation (First Mental Health Specialist)
The professional role of the person making the first specialist assessment
 Format is a free text or coded in SAP 7.0
6.8
Assessment Date
Date assessed by other relevant professional
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.9
Assessment Location
Location where the other health professional conducted assessment
 Format is free text or 2 numeric characters to indicate location
6.10
Diagnosis ICD (post specialist assessment)
The medical diagnosis code ICD format arising from the assessment by the specialist service.
 Format is 6 alphanumeric characters
6.11
Diagnosis (Read)
The medical diagnosis code Read format arising from the assessment by the specialist service.
 Format is 6 alphanumeric characters
6.12
Diagnosis (Snomed)
The medical diagnosis code Snomed format arising from the assessment by the specialist service.
 Format is 6 alphanumeric characters
6.13
Referred On? (to Psychological Therapies)
To capture whether the person was referred onto specialist psychological therapies
 Suggested format is 2 numeric characters (to indicate Yes, No, Unknown)
6.14
Reason for Referral
The reason the person was referred for psychological therapies.
 Format is 2 numeric characters (to indicate reason)
6.15
Date (Referral to Psychological Therapies)
The date a referral was made for psychological therapy.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
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OP MH Depression Dataset
6.16
OP MH Depression Data Manual
Date (Seen by Psychological Therapist)
The date the person was seen by a psychological therapist.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.17
Therapy Type
The type of specialist mental health service the person was referred to.
 Format to be agreed
6.18
Referred On? (to other Therapies)
To capture whether the person was referred onto another type of therapy
 Format is 2 numeric characters (to indicate Yes, No, Unknown)
6.19
Reason (for Referral)
The reason the person was referred for other therapies.
 Format is 2 numeric characters (to indicate reason
6.20
Date (Other Therapies)
The date a referral was made for other types of therapy.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.21
Date (Seen by other Therapist)
The date the person was seen by another type of therapist.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.22
Referred On? (to Specialist Mental Health Service Secondary Care)
To capture whether the person was referred onto another a specialist mental health service at secondary care
level.
 Format is 2 numeric characters (to indicate Yes, No, Unknown)
6.23
Referral Source
Source of referral to specialist mental health service (ECT)
 Format is 2 numeric characters (to indicate reason)
6.24
Reason (for Referral)
The reason the person was referred for ECT therapy.
 Format to be agreed
6.25
Referral Date (ECT Therapy)
The date a referral was made for ECT therapy.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.26
Date (Start Date ECT Therapy)
The date the ECT therapy was started.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.27
Referred On? (to Psychological Therapies, Secondary Care)
To capture whether the person was referred onto psychological therapies at secondary care level.
 Format is 2 numeric characters (to indicate Yes, No, Unknown)
Draft Version 0.2
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OP MH Depression Dataset
6.28
OP MH Depression Data Manual
Referral Source
Source of referral to psychological therapies
 Format to be confirmed
6.29
Date (Referral to Psychological Therapies Secondary Care)
The date a referral was made for psychological therapy in a secondary care setting.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.30
Start Date (Seen by Psychological Therapies Secondary Care)
The date the person was seen by a psychological therapist and therapy was started.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.31
Therapy Type
The type of specialist mental health service the person was referred to.
 Format to be agreed
6.32
Referred On? (to Other Therapies, Secondary Care)
To capture whether the person was referred onto another type of therapy at secondary care level.
 Format is 2 numeric characters (to indicate Yes, No, Unknown)
6.33
Reason for Referral
The reason the person was referred for other therapies
 Format is 2 numeric characters (to indicate reason)
6.34
Date (Other Therapies)
The date a referral was made for other types of therapy.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.35
Date (Seen by Other Therapist)
The date the person was seen by a another type of therapist in a secondary care setting.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.36
Therapy Type
The type of specialist mental health service the person was referred to.
 Format is 2 numeric characters (to indicate type of service)
6.37
Date Discussed
The date on which the patient is reviewed.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
6.38
Review Date
The date on which the patient is reviewed.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
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OP MH Depression Data Manual
Patient and Doctor’s Perception of the Patient’s Progress and
Condition
Data items 7.1 to7.4 relate to progress review and related date. They originate from a number of business
requirements (see below) and can be referenced back to the National Service Framework for Older People,
clinical guidelines and expert opinion from the mental health WG.
Table 13
Business Requirements Linked To Patient and Doctor’s Perception of the
Patient’s Progress and Condition
Ref
Business Requirement
12
Patients undergoing treatment for
depression should undergo regular
review: appropriate to their condition
Both the patient’s and doctor’s
perception of the patient’s progress
should be recorded at each review
13
Table 14
7.2
7.3
7.4
7.1
Comment
WG
Data Items: Patient and Doctor’s Perception of the Patient’s Progress and
Condition
Data Item
7.1
Document of
Origin
WG
REVIEW DATE
PROGRESS AT
REVIEW
(PATIENT’S
PERCEPTION)
PROGRESS AT
REVIEW
(DOCTOR’S
PERCEPTION)
PROFESSIONAL
ROLE IN
ORGANISATION
(REVIEW
CONSULTATION)
Description
Date on which the patient is
reviewed
The patient’s perception of their
progress as discussed during the
review consultation
The healthcare professional’s
perception of the patient’s progress
as discussed during the review
consultation
This is the role in the organisation of
the person conducting the review
Purpose
To monitor that patient’s with depression
are provided with regular review as
appropriate to their condition
Business Requirements Draft 0.8
Requirement 12, 13
Both the patient’s and doctor’s
perception of progress should be
recorded for those patients with
depression at each review
Business Requirements Draft 0.8
Requirement 13
Identifies contact details for the
professional involved with the patient’s
review
Review Date
The date on which the patient is reviewed.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
7.2
Progress at Review (Patient’s Perception)
The patient’s perception of their progress as discussed during the review consultation.
 Format is free text (maximum 255 alphanumeric characters)
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OP MH Depression Data Manual
Progress at Review (Doctor’s Perception)
The healthcare professional’s perception of the patient’s progress as discussed during the review consultation.
 Format is free text (maximum 255 alphanumeric characters)
7.4
Professional Role in Organisation (Review Consultation)
The role in the organisation of the person conducting the review.
 Format is free text (maximum 255 alphanumeric characters)
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8
OP MH Depression Data Manual
Access to Other Services/Facilities
Data items 8.1 to 8.25 relate to other referrals and treatments, including hospital-based, emergency, 24 hour
crisis support, and related dates. They originate from a number of business requirements (see below) and can be
referenced back to the National Service Framework for Older People, NICE clinical guidelines and expert
opinion from the mental health WG.
Table 15
Business Requirements Linked To Referral to Specialist & Referral to
Specialist Treatments and Therapies
Ref
Business Requirement
14
There should be access to inpatient
and day treatment facilities if required
Intermediate care (emergency and
planned) and 24 hour access to crisis
support services should be available
to patients and cares
15
Table 16
8.2
8.3
8.4
8.5
8.6
Comment
This business requirement also needs to be
monitored via organisational audit
Data Items: Access to Other Services/Facilities
Data Item
8.1
Document of
Origin
WG
DATE
(CONSULTATION RE
AVAILABLE
SERVICES)
REFERRAL DATE
(HOSPITAL
PROVIDER SPELL)
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE
END DATE
REFERRAL DATE
(DAY TREATMENT)
Description
The date the person received a
consultation explaining the
various services available to
patients and carers including 24
hour support
The date the person was referred
for a Hospital based provider
spell
This is the role in the
organisation of the referring
source for the hospital facilities.
The start date that the person
attended a hospital based spell
The end date that the person
completed a hospital based spell
The date the person was referred
for a Day Treatment provider
spell
Purpose
To monitor good practice in advising
patients and carers of available services.
This requirement should also be
monitored via the organisational audits
Business Requirements Draft 0.8
Requirement 15
There should be access to Inpatient
facilities if required
Business Requirements Draft 0.8
Requirement 14
Identifies role and contact details for the
referring source
Monitor time between referral and
admission for hospital based
facilities/treatment
Business Requirements Draft 0.8
Requirement 14
Monitor the period of time that the
patient utilised hospital based
facilities/treatment
Business Requirements Draft 0.8
Requirement 14
There should be access to day treatment
facilities if required
Business Requirements Draft 0.8
Requirement 14
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8.7
8.8
8.9
8.10
8.11
8.12
8.13
8.14
8.15
8.16
8.17
8.18
8.19
8.20
Data Item
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE
(DAY TREATMENT)
END DATE (DAY
TREATMENT)
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE
(EMERGENCY
RESPITE STAY)
END DATE
(EMERGENCY
RESPITE)
REFERRAL DATE
(PLANNED
INTERMEDIATE
CARE FACILITIES)
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE
(PLANNED
INTERMEDIATE
CARE STAY)
END DATE (PLANNED
INTERMEDIATE
CARE STAY)
REFERRAL DATE
(EMERGENCY
INTERMEDIATE
FACILITIES)
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE
(EMERGENCY
INTERMEDIATE
CARE STAY)
END DATE
(EMERGENCY
INTERMEDIATE
CARE STAY)
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Description
This is the role in the
organisation of the referring
source for the Day Treatment.
Purpose
Identifies role and contact details for the
referring source
The start date that the person
attended a day treatment based
spell
Monitor time between referral and
admission for day treatment based
facilities/treatment
The end date that the person
completed a day treatment based
spell
Business Requirements Draft 0.8
Requirement 14
Monitor the period of time that the
patient utilised day treatment based
facilities
This is the role in the
organisation of the referring
source for the emergency respite
facilities.
The start date that the person was
admitted for emergency respite
care
The end date that the person
completed a planned respite care
stay
The date the person was referred
for Planned intermediate care
facilities
This is the role in the
organisation of the referring
source for the Planned
Intermediate care facilities.
The start date that the person was
admitted for Planned
Intermediate care
The end date that the person
completed a planned
intermediate care stay
The date the person was referred
for emergency intermediate care
facilities
This is the role in the
organisation of the referring
source for the emergency
intermediate care facilities.
The start date that the person was
admitted for emergency
Intermediate care
The end date that the person
completed a emergency
intermediate care stay
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Business Requirements Draft 0.8
Requirement 14
Identifies role and contact details for the
referring source
Monitor time between referral and
admission for planned respite care
Monitor the period of time that the
patient utilised planned respite care
facilities
Monitor the uptake of planned
intermediate care facilities which should
be available if required for persons with
depression
Identifies role and contact details for the
referring source
Monitor time between referral and
admission for planned intermediate care
spells
Monitor the period of time that the
patient utilised planned intermediate care
facilities
Monitor the uptake of emergency
intermediate facilities which should be
available if required for persons with
depression
Identifies role and contact details for the
referring source
Monitor time between referral and
admission for planned Intermediate care
Monitor the period of time that the
patient utilised emergency Intermediate
care facilities which should be available
for persons with depression
OP MH Depression Dataset
8.21
8.22
8.23
8.24
8.25
8.1
OP MH Depression Data Manual
Data Item
REFERRAL DATE (24
HOUR CRISIS
SUPPORT)
Description
The date the person was referred
for 24 hour crisis support
services
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING
SOURCE)
START DATE (24
HOUR CRISIS
SUPPORT SERVICES)
END DATE (24 HOUR
CRISIS SUPPORT
SERVICES
24 HOUR SUPPORT
CRISIS SUPPORT
SERVICE USED
This is the role in the
organisation of the referring
source for the 24 hour crisis
support services
The start date that the person
used 24 hour crisis support
services
The end date that the person
stopped using 24 hour crisis
support services
The actual service(s) that the
person or their carers used
Purpose
Monitor the uptake of 24 hour crisis
support services which should be
available if required for persons with
depression
Identifies role and contact details for the
referring source
Monitor time between referral and
admission for planned respite care
Monitor the period of time that the
patient utilised 24 hour crisis support
services
Monitor uptake of specific 24 hour
support services
Date (Consultation re: Available Services)
The date the person received a consultation explaining the various services available to patients and carers
including 24 hour support
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.2
Referral Date (Hospital Provider Spell)
The date the person was referred for a hospital based provider spell.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.3
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for hospital facilities
 Format is a maximum of 255 alphanumeric characters
8.4
Start Date
The start date that the person attended a hospital based spell.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.5
End Date
The end date that the person completed a hospital based spell.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.6
Referral Date
The date the person was referred for a day treatment provider spell.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.7
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for day treatment.
 Format is a maximum of 255 alphanumeric characters
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8.8
OP MH Depression Data Manual
Start Date (Day Treatment)
The start date that the person attended a day treatment based spell
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.9
End Date (Day Treatment)
The end date that the person completed a day treatment based spell.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.10
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for emergency respite facilities
 Format is a maximum of 255 alphanumeric characters
8.11
Start Date (Emergency Respite)
The start date that the person was admitted for emergency respite care.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.12
End Date (Emergency Respite)
The end date that the person completed a planned respite care stay.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.13
Referral Date (Planned Intermediate Care Facilities)
The date the person was referred for planned intermediate care facilities.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.14
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for planned intermediate care facilities
 Format is a maximum of 255 alphanumeric characters
8.15
Start Date (Planned Intermediate Care Stay)
The start date that the person was admitted for planned intermediate care.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.16
End Date (Planned Intermediate Care)
The end date that the person completed a planned intermediate care stay.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.17
Referral Date (Emergency Intermediate Care Facilities)
The date the person was referred for emergency intermediate care facilities.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.18
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for emergency intermediate care facilities
 Format is a maximum of 255 alphanumeric characters
8.19
Start Date (Emergency Intermediate Care Stay)
The start date that the person was admitted for emergency intermediate care.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
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8.20
OP MH Depression Data Manual
End Date (Emergency Intermediate Care Stay)
The end date that the person completed an emergency intermediate care stay.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.21
Referral Date (24 Hour Crisis Support)
The date the person was referred for 24 hour crisis support services.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.22
Professional Role in Organisation (Referring Source)
The role in the organisation of the referring source for 24 hour crisis support services
 Format is a maximum of 255 alphanumeric characters
8.23
Start Date (24 Hour Crisis Support Services)
The start date that the person used 24 hour crisis support services.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.24
End Date (24 Hour Crisis Support Services)
The end date that the person stopped using 24 hour crisis support servcies.
 Format is 8 numeric characters with 2 spaces to indicate year-month-day: (4-2-4)
8.25
24 Hour Crisis Service Used
The actual service(s) that the person or their carers used.
 Format to be identified
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OP MH Depression Dataset
C
Appendices
a
List of Abbreviations
b
Read Codes
c
ICD10 Codes
d
References
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a
OP MH Depression Data Manual
List of Abbreviations
A&E
Accident and Emergency
DoH
Department of Health
ECT
Electroconvulsive Therapy
GMS
General Medical Services
GP/GMP
General Practitioner/General Medical Practioner
ICD-10
International Classification of Diseases (version 10)
IT
Information Technology
MDT
Multi-disciplinary Team
MHMDS
Mental Health Minimum Data Set
NHS
National Health Service
NHSIA
NHS Information Authority
NICE
National Institute for Clinical Excellence
NPfIT
National Programme for Information Technology
NSF
National Service Framework
NSTS
NHS Strategic Tracing Service
PCT
Primary Care Trust
(Read code) (Clinical code)
SAP
Single Assessment Process
Snomed
Systemized Terms Nomenclature of Medicine
UK
United Kingdom
V(1.2)
version (1.2)
WG
Working Group
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b
OP MH Depression Data Manual
Clinical Codes
CLINICAL
TERM
READ
CODE
TERM
Id
ICD-10
Depression
X00SO
Y01FA
F32.9[D]
(to be completed)
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c
OP MH Depression Data Manual
References
Older People Information Strategy
National Service Framework for Older People
National Institute for Clinical Excellence
NHS Data Dictionary
NHS Tracing Service
NSF Medicines
Single Assessment Process for Health and Social Care for Older People
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