Since the creation of an expanded set of data specifications was commissioned by the Discovery Collaborative, one of the healthcare areas it focuses on is Social Care.

You can find the expanded data specification for the Social Care dataset outlined below, displaying each section with its Name, Description, Conformance, and Codes with their matching values which makes up the Primary Value Set. To see the full specification which includes Data Types, FHIR Targets, and the Secondary Value Sets, please go to:

To read more about the Social Care aspect of this project, please find the full project summary at:

=== Submission Information ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|LA CODE
|For every row of data, please record the LA code associated with all social care collections e.g. for Lincolnshire, the LA code is503.
This will be used to ensure thatall data rows can be attributed to specific Local Authorities, and to derive the Local Authority Name.
|M
|
|-
|REPORTING PERIOD START DATE
|The reporting period start date for the data being submitted. Typically, this will the firstday of the reporting month, quarter, or year
|M
|
|-
|REPORTING PERIOD END DATE
|The reporting period end date for the data being submitted. Typically, this will be last day of the reporting month, quarter, or year
|M
|
|} 

=== Person Details. ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PERSON UNIQUE IDENTIFIER
|An LA Client ID – a Person Unique Identifier - can be supplied to identify events for the same person, for whom the NHS number is missing
|M
|
|-
|NHS NUMBER
|NHS Number should be provided, as the national unique identifier for persons, which can be used to link to other data sources.
|M
|
|-
|FIRST NAME
|
|M
|
|-
|LAST NAME
|
|M
|
|-
|GP PRACTICE NAME
|
|M
|
|-
|GP PRACTICE CODE
|
|M
|
|-
|GENDER
|Gender is defined as the gender the individual considers themselves to be. ‘Other’ has been added for clients who do not identify as male or female. ‘Unknown’ should be used where the client’s gender has not been recorded.
|M
|2 - Female

1 - Male

X - Not known

Not stated/recorded (or unborn)

Neither
|-
|ETHNICITY
|Ethnicity should be completed in line with the current NHS Digital Data Dictionary to vastly improved diversity monitoring to ‘Unknown’
should be used where the client’s ethnicity has not been recorded
|M
|A - White (English / Welsh / Scottish / Northern Irish / British)
B - White Irish

- White (Gypsy or Irish Traveller)

C - Any other White background

D - White and Black Caribbean

E - White and Black African

F - White and Asian

G - Any other mixed / multiple ethnic background

H - Indian

J - Pakistani

- Bangladeshi

- Chinese

L - Any other Asian background

N - African

M - Caribbean

P - Any other Black / African / Caribbean background

- Arab

S - Any other ethnic group

Z - Refused

99 - Undeclared / Not known

- Other Ethnic Group:

- Black/African/Caribbean/Black British

- Asian/Asian British

- Mixed/Multiple

- a) WBRI

- b) WIRI

- c) WIRT

- d) WOTH

- e) WROM

- f) MWBC

- g) MWBA

- h) MWAS

- i) MOTH

- j) AIND

- k) APKN

- l) ABAN

- m) AOTH

- n) BCRB

- o) BAFR

- p) BOTH

- q) CHNE

- r) OOTH

- s) REFU

- t) NOBT

A - White British

C - Other White

G - Other mixed

L - Other Asian

P - Other Black

S - Other

T - White Gypsy or Roma or Traveller or Irish Traveller

Z - Not stated

99 - Ethnicity is unknown
|-
|DATE OF BIRTH
|"The date of birth should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.

For Annex A the additional guidance is provided: If an expected birth date is available for an unborn child, enter this date, otherwise leave blank.

If no date of birth or expected date of birth is not available, leave blank.
|M
|
|-
|DATE OF DEATH
|Date of death recorded as appropriate. For an individual who is not dead, please input the value
|M
|
|-
|PRIMARY SUPPORT REASON
|The latest known Primary Support Reason (PSR) in the reporting period should be recorded for the service user against each event row.

If the PSR is not determined i.e., the service user’s journey does not progress past the request stage, then ‘Unknown’ should be chosen.

If a service user receives multiple services for different reasons, the most relevant PSR to each event should be chosen.

If a service user is also supported by the local authority as an unpaid carer, the event rows that relate to the support provided to the person as a service user should show the most relevant support reason, and the event rows that relate to the person supported because of their caring role, should have a PSR of Social Support
|M
|Physical Support: Access & mobility only

Physical Support: Personal care support

Sensory Support: Support for visual impairment

Sensory Support: Support for hearing impairment

Sensory Support: Support for dual impairment

Support with Memory & Cognition

Learning Disability Support

Mental Health Support

Social Support: Substance misuse support

Social Support: Asylum seeker support

Social Support: Support for Social Isolation/Other

PSR Not Known

Sensory Support

Physical Support

Social Support

No Support Reason

Not Known
|-
|POSTCODE
|The postcode of the person’s normal place of residence should be recorded alongside all event rows for that client in the return. The postcode will be used to assist with identifying missing NHS numbers and to derive geographical fields to support analysis. Where care services are received at the person’s home, the postcode should reflect that. Where someone now lives in a residential or nursing home, the postcode of the residential/nursing home should be used. The same should also apply to clients who move to an out-of-area residential home; the postcode of the out-of-area residential/nursing home should be recorded. Under these circumstances, the activity should be reported by the CASSR where the person is ordinarily resident, where the LA holds responsibility for the person in an out of county placement. Clients who are placed in care homes temporarily should not use the postcode of the care home, as this has not yet become their normal place of residence. For unpaid carers, it is recognised that caring roles can be across LA borders, so as with above, the postcode of the carer’s normal place of residence should be recorded
|M
|
|-
|ACCOMMODATION STATUS
|This data item is collected for clients with a Learning Disability aged 18 to 64, althoughthere is growing appetite for this to be captured for all adult client groups and age bands. For CLD it is required that the Accommodation Status is linked to the latest known address / postcode. ‘Unknown’ should be used where the client’s accommodation status has not been recorded.
|M
|01 Owner occupier or shared ownership scheme
Tenant

03 Tenant - private landlord

Settled mainstream housing with family / friends

Supported accommodation / supported lodgings / supported group home

Shared Lives scheme

Approved premises for offenders released from prison or under probation supervision

Sheltered housing / extra care housing / other sheltered housing

08 Mobile accommodation for Gypsy / Roma and Traveller communities

Rough sleeper / squatting

17 Night shelter / emergency hostel / direct access hostel

Refuge

19 Placed in temporary accommodation by the council (inc. homelessness resettlement)

15 Staying with family / friends as a short-term guest

Acute / long-term healthcare residential facility or hospital

Registered care home

Registered nursing home

21 Prison / Young offenders institution / detention centre

98 Other temporary accommodation

9 Unknown
|-
|EMPLOYMENT STATUS
|This data item should be prioritised for clients with a Learning Disability aged 18 to 64. Where possible, LAs should also include the employment status of unpaid carers. Where possible, LAs should include the employment status of unpaid carers captured within the reporting period. ‘Unknown’ should be used where the client’s employment status has not been recorded
|M
|Paid: Less than 16 hours a week
Paid: 16 or more hours a week

02 Not in Paid Employment (seeking work)

Not in Paid Employment (not actively seeking work / retired)

07 Not in Paid Employment (voluntary work only)

Unknown
|-
|HAS NPAID CARER CARER
|Formerly – ‘Has Informal Carer’ (changed to better represent the role of unpaidcarers and align with current terminology. This should not affect the data submitted.) Whether the person receives support from an informal carer gives a holistic view of a person's support package. These rules are closely aligned to the Carer Status from SALT LTS001b table 2 but is expected for all event types in the dataset, not just where long term support services are provided to the client. This variable is also relevant for unpaid carers, to determine if they themselves are being cared for. It is recognised that there can be multiple informal carers known to the client and actively providing support. For the purposes of the CLD collection, a value of 'Yes' would indicate that at least one carer is known to the client. ‘Unknown’ should be used where it is not recorded if the carer unpaid or not.
|M
|Yes
No

Not known
|-
|AUTISM SPECTRUM DISORDER (ASD)
|A single variable of ‘Autism Spectrum Disorder (ASD)’ to replace the two ‘Autism’ and ‘Asperger’s Syndrome’ variables. ASD is to be adopted in 2022 by the World Health Organisation (WHO) using the latest version of the International Classification of Diseases (ICD-11). In the Light Touch Review of SALT (2018) the National Autistic Society did not see much value in the existing data capture of Autism and Asperger Syndrome, and owingto updates in diagnostic criteria, these Reported Health Conditions / comorbid conditions no longer matched the emerging single categorisation of ‘Autism SpectrumDisorder’. As with Reported Health Conditions previously reported in SALT, ASD Should be diagnosed and relevant to care needs. ‘Unknown’ should be used where the client’s ASD status has not been recorded
|M
|Yes

No

Not known
|-
|VISUAL IMPAIRMENT
|For the purposes of CLD visual impairment should be recorded for all people who are in scope of the CLD collection. ‘Unknown’ should be used where the client’s Visual status has not been recorded
|M
|Blind/severely sight impaired

Partial sight/sight impaired

No visual impairment

Unknown
|-
|HEARING IMPAIRMENT
|For the purposes of CLD Hearing impairment is reported for all people who are in scope of the CLD collection. ‘Unknown’ should be used where the client’s hearing status has not been recorded.
|M
|Deaf with speech
Deaf without speech

Hard of hearing

No hearing impairment

Unknown
|-
|DEMENTIA
|Dementia should be reported for every client in scope of the CLD collection. As with Reported Health Conditions previously reported in SALT, Dementia should be diagnosed and relevant to care needs. It is expected that Dementia should be identified from young-onset Dementia to diagnosed conditions such as Alzheimer's disease, vascular dementia, frontotemporal dementia, and more. Mild Cognitive Impairment (MCI) would not be included as the symptoms are not usually severe enough to interfere significantly with daily life. ‘Unknown’ should be used where the client’s Dementia status has not been recorded.
|M
|Yes

No

Not known
|} 

=== Events (ALL) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|EVENT TYPE
|Event types which occur in the local authority within the reported timeframe should be captured for service users and carers.
This includes:

• Requests received in the reporting period.

• Assessments and reviews commenced and/or completed in the reporting period. No open or ongoing requests, assessments or review events are required, each row should include an event outcome.

• Service events that started or ended within the reporting period, or where the service was open and ongoing at the end of the reporting period. This includes events where the start date was before the start of the reporting period, were open at the end of the reporting period or ended after the reporting period. Service events are the only event type in CLD that can be open and ongoing, with an event start date, but no event end date.

• Cancelled events should be excluded from the collection. Suspended services should be included as originally intended. It is recognised that different LA’s have different business rules and practices, but the four key steps in the social care pathway are common to all, with data collected on each aspect reported by LAs at some point in the past. These are Requests, Assessments, Services, and Reviews
|M
|Request

Assessment

Service

Review
|-
|EVENT REFERENCE
|The event reference facilitates identifying events for data quality reporting and is a mechanism to ensure that event rows are not duplicated. It is anticipated that some Local Authority case management systems willautomatically create a unique reference for events when the record is created. Where the event reference is automated, it can be included as the event reference. W here an automated unique event reference is not available, LAs should consider a local method to derive an event reference, using other data items in the collection such as matching dates, event types and/or a combination of other data fields
|M
|
|-
|EVENT START DATE
|Required for all event rows, this will be the date the event started, which may differ from the date the event was recorded on the case management system. For example, where a client received home care from the 20th March, but the service was recorded and authorised on the 22nd March, the start date recorded in CLD should be 20th March
|M
|
|-
|EVENT END DATE
|Event end date should be entered for all events completed or ended during the collection period. An event end date is required for all request, assessment and review events. It is feasible to have an event start and event end on the same date, for example a request for support received by a contact centre which is started and completed over the phone. In this case, please record the same date for both the event start date and end date.
|M
|
|-
|EVENT DESCRIPTION
|The free text ‘Event Description’ provides context and can be the system description of the service, allowing Local authorities to assign further clarification and meaning to event rows. Descriptions of events will vary between Local Authorities
|M
|
|-
|EVENT OUTCOME
|The purpose of this field is to help determine the path taken by individuals in the social care system, particularly in situations in which the sequence of events is not be feasible to infer from linking event records. It is intended to reflect the reason for the ending of an event or indicate the resulting procedure. As a mandatory field, all events require an Event Outcome. It is acknowledged that the Event Outcome is not always easy to extract from LA activity systems. LAs should select the Event Outcomes that best represent the outcomes of each event based on available information. Event outcomes should be known at the point when the event is completed, with no further processing required. They will indicate whether the client’s pathway has ended or indicate the subsequent step in the social care journey. There is no requirement to track cases and derive the usual SALT sequel attached to each unique event. The intention is that the processing of sequels will be done centrally following submission of the data, using agreed transformation rules based on linking records. Event outcomes can be amended for event records that are included in later submissions, where the event outcome has changed or been corrected. For situations in which the event has concluded but the next event is delayed, the expected Event Outcome should be included for the completed event. If there is a change of circumstance that leads to the expected event not taking place, the event outcome for the completed event can be revised in future submissions For example, if an individual that has made a request and is put on a triage list for an assessment, the Event Outcome for the request should be “Progress to Assessment”. If the individual is deemed not to require an assessment or an emergency event such as hospital admission takes place prior to the assessment taking place, the Event Outcome of the request can be revised to reflect the situation. In the case of a service which is open or ongoing at the end of the reporting period, the event outcome should be ‘Provision of Service’.
|M
|Progress to Reablement/ST-Max

Progress to Assessment / Unplanned

Review

Admitted to hospital

Progress to Re-assessment

Progress to Support Planning / Services

Progress to End of Life Care

No change in package

Service ended as planned

NFA - Moved to another LA

NFA - 100%

NHS funded care

NFA - Self-funded client (inc 12wk disregard)

NFA - Support declined

NFA - Information & Advice / Signposting only

NFA - Deceased
|} 

=== Events (Requests Only) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|REQUEST: ROUTE OF ACCESS
|Route of Access is required for all requests for support whether this is for a NEW or EXISTING client. Requests captures referrals from other services/ professionals as well as direct contacts from people contacting the LA on someone else’s behalf. The recording of route of access should follow the SALT convention for STS001 and apply equally to service users and carers, although with the latter, this may not be captured on local systems, so a default of ‘Community / Other route’ should be chosen
|M
|Planned Entry (Transition)

Discharge from Hospital

Diversion from Hospital Services

Community / Other route

Prison

Self-Funder with depleted funds

Self-Funder with depleted funds - 12-wk disregard or DPA

Discharge from Reablement

Transfer from Other LA
|} 

=== Events (Assessments Only) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|ASSESSMENT TYPE
|The CLD LA Reference Group saw the benefit of adding a new variable with structured assessment type values to match SALT concepts, and LAs may choose to capture the system assessment name using the event description. This field has been made mandatory and amended to capture Financial Assessments to support monitoring of Charging Reform implementation. It is recognised that LAs will have different assessment practices and use proportional assessments such as an ‘Initial Conversation’ style assessment or a ‘3-stage’ assessment. LAs will have to de cide how best to reflect this activity as Long Term or Short Term Assessments. Long Term Assessments should include all needs assessments where there is an eligibility determination
|M
|Short Term Assessment

Long Term Assessment
|-
|INFORMAL CARER INVOLVED IN ASSESSMENT
|
|M
|Yes

No

Don't know
|} 

=== Events (Services Only) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SERVICE TYPE
|
|M
|Short Term Support: ST-Max

Short Term Support: Ongoing Low Level

Short Term Support: Other Short Term

Long Term Support: Nursing Care

Long Term Support: Residential Care

Long Term Support: Community

Long Term Support: Prison
|-
|SERVICE COMPONENT
|The reference group saw the benefit of adding a new ‘service component’ field to supplement the existing ‘Service Type’ variable. The following values have been agreed. For instances where a service provision is a direct payment, but that it has a known specified purpose, the purpose should be represented in the Service Component field and Direct Payment should be selected in the Delivery Mechanism field. For cases in which the purpose for the direct payment is not specific or known, Direct Payment should be selected in the Service Component field. unknown. For example, where a direct payment is made for carer respite, the Service Component should be recorded as Carer Respite and the Delivery Mechanism field can be used to record Direct Payment
|M
|Reablement

Short Term Nursing Care

Short Term Residential Care

Long Term Nursing Care

Long Term Residential Care

Home Support

Day Support

Meals

Transport

Equipment

Direct Payment

Shared Lives
|-
|DELIVERY MECHANISM (LONG TERM COMMUNITY OR PRISON ONLY)
|Values have been consolidated and apply to carers and prison or community settings and can be identified separately from the service type variable. The inclusion of delivery mechanism provides further insight to the financial information reported for each service row. For CLD the Delivery Mechanism is specific to the service line. This is a change to the Service Setting/ Delivery Mechanism methodology described in SALT, which is based on the hierarchy of all services recorded for the client or carer
|
|Community: Direct Payment

Community: CASSR Managed Personal Budget

Community: CASSR Commissioned Support

Prison: CASSR Managed Personal Budget

Prison: CASSR Commissioned Support
|} 

=== Events (Reviews Only) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|REVIEW REASON
|The Significant Event in SALT LTS002 has been renamed as Review Reason for the Client Level Data collection. As with route of access, rather than adding a new carer specific review reason, please choose the most appropriate review reason if known, else default to ‘planned’ for all carer reviews
|M
|Planned

Unplanned - Hospital (Planned and unplanned episodes)

Unplanned - Carer related

Unplanned - Safeguarding concern

Unplanned - Other Reason

Unplanned - Provider Failure

Unplanned - Change in Commissioning arrangements
|-
|REVIEW OUTCOMES ACHIEVED
|There is currently a gap in person-centred outcomes measurement linked specifically to needs and packages. To address this, ‘review outcomes achieved’ has been added
|M
|Fully Met

Partially Met

Not Met
|} 

=== Costs (Services Only) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|UNIT COST (£)
|
|M
|
|-
|COST FREQUENCY (UNIT TYPE)
|There is currently a gap in person-centred outcomes measurement linked specifically to needs and packages. To address this, ‘review outcomes achieved’ has been added with values equivalent to the Safeguarding Adults Collection (SAC) return, Making Safeguarding Personal (MSP) table Fully met e.g. if all outcomes are fully met Partially met e.g. if at least one is fully or partially met Not met e.g. if no outcomes are met Data item: Defined list The item is included as an overview of whether support services have enabled the client to achieve their stated outcomes. It will provide some insights into the success of LA funded support and unmet need for clients known to the LA. It is expected that, in line with Care act 2014 eligibility, clients in receipt of long term support will have specified at least two personal outcomes where there is a need. The process for deciding the extent to which an outcome has been achieved will differ in each Local Authority, but reviews should be conducted as a discussion with the relevant individuals, where the reviewer arrives at a professional judgement on the achievement of their outcomes
|M
|Per Session

Hourly

Weekly

Fortnightly

4-weekly

Monthly

Quarterly

Annually

One-off
|-
|PLANNED UNITS PER WEEK
|Required for services only where the unit cost occurs more frequently than weekly such as hourly, daily, or per session
|M
|
|} 

=== SAC ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Achieved Outcomes
|Looks at whether desired outcomes have been achieved is part of Making Safeguarding Personal (MSP). The process for deciding whether an outcome has been achieved will be different for different local authorities. Ideally the adult at risk or their representative should identify whether their outcomes have been met but sometimes it is the safeguarding team that would make this decision. We would not expect 100 per cent of expressed outcomes to be achieved.
|O
|Fully Achieved

Partially

Achieved

Not Achieved
|-
|Age Group (SAC)
|The age of the individual on the last day of the reporting period or age at the time of death if an individual has died. Where the age of an individual has not been recorded, please record them in the Not Known column. We only expect this category to be used in a minority of cases.
|Mandatory for Section 42 Safeguarding Enquires, Optional / Voluntary for Safeguarding Concerns and Other Safeguarding Enquiries
|18-64

65-74

75-84

85-94

95+

Not Known
|-
|Concluded Enquiries
|When the safeguarding investigation is complete and the conclusions and actions have been decided. Only enquiries that concluded within this reporting year should be recorded. This can include cases that began in a previous reporting period.
|Mandatory for Concluded Section 42 Enquires, Optional / Voluntary for Concluded Other Enquires
|Concluded section 42 enquiries

Concluded other safeguarding enquiries
|-
|Desired Outcomes
|Looks at whether desired outcomes have been achieved is part of Making Safeguarding Personal (MSP). Desired outcomes are the wishes of the adult at risk or their representative which have been expressed at some point during the information gathering or enquiry phases.
|O/V
|Yes they were asked and outcomes were expressed

Yes they were asked but no outcomes were expressed

No

Don't Know

Not recorded
|-
|Location of risk
|Describes where the alleged safeguarding incident took place.
|Mandatory (except when relating to Other Concluded Safeguarding Enquires which are Optional / voluntary)
|Own home

In the community (excluding community services)

In a community service

Care home - nursing

Care home - residential

Hospital - acute

Hospital - mental health

Hospital - community

Other
|-
|Mental Capacity Status
|Detailing, for each enquiry, whether the adult at risk lacked capacity to make decisions related to the safeguarding enquiry.
|Mandatory for Concluded Section 42 Enquires, Optional / Voluntary for Other Concluded Enquires
|Yes, they lacked capacity

No, they did not lack capacity

Don't Know

Not recorded
|-
|Reported Health Condition
|Reported Health Conditions (RHCs) are the reasons why support is provided to the adult at risk. A RHC relates to an illness, disability or condition affecting the client - and diagnosed by a healthcare professional - that contributes to the client's need for support. Individuals should only have a RHC on the local system if they are receiving support. However, not all individuals who receive support will have a RHC. We would expect RHCs to be recorded on the local system as part of a social care assessment or review. We do not expect local authorities to assess RHCs as part of the safeguarding process and therefore we would expect RHC data to be taken from existing information on the local care management system.
|Optional / Voluntary, except for with regards to Section 42 enquires for Autism and Asperger's sub classifications which are mandatory.
|
|-
|Risk Assessment Outcomes
|Was a risk identified and was any action taken / planned to be taken?
|Mandatory for Concluded Section 42 Enquires, Optional / Voluntary for Other Concluded Enquires
|Risk identified and action taken

Risk identified and no action taken

Risk - Assessment inconclusive and action taken

Risk - Assessment inconclusive and no action taken

No risk identified and action taken

No risk identified and no action taken

Enquiry ceased at individual's request and no action taken
|-
|Risk Outcomes
|Where a risk was identified, what was the outcome / expected outcome when the case was concluded? This describes what happened to the risk being actioned. It is the decision of the safeguarding officer as to which option to record but the views of the individual at risk (or the person acting in their best interests) and other colleagues should be considered where possible.
|Mandatory for Concluded Section 42 Enquires, Optional / Voluntary for Other Concluded Enquires
|Risk Remained

Risk Reduced

Risk Removed
|-
|Safeguarding Activity
|Safeguarding Activity relates to cases as opposed to individuals (unlike Individuals Involved in Safeguarding Activity). Collects distinct counts of the following: • Total Number of Safeguarding Concerns received during the reporting period • Total Number of Section 42 Safeguarding Enquiries commenced during the reporting period • Total Number of Other Safeguarding Enquiries commenced during the reporting period Please note that these counts relate to cases and not individuals
|Mandatory
|Total Number of Safeguarding Concerns

Total Number of Section 42 Safeguarding Enquiries

Total Number of Other Safeguarding Enquiries
|-
|Safeguarding Adult Reviews 1
|When an adult at risk dies from or suffers from serious harm, a SAR is conducted to identify how local professionals and organisations can improve the way they work together. A Safeguarding Adults Board (SAB) would usually make the decision to instigate a SAR and a report will be produced to document the findings and recommendations. This is a count of SARs which concluded during the reporting year.
|Mandatory
|SARs where one or more individual died

SARs where no individuals died
|-
|Safeguarding Adult Reviews 2
|When an adult at risk dies from or suffers from serious harm, a SAR is conducted to identify how local professionals and organisations can improve the way they work together. A Safeguarding Adults Board (SAB) would usually make the decision to instigate a SAR and a report will be produced to document the findings and recommendations. This is a count of individuals involved in SARs which concluded during the reporting year.
|Mandatory
|Individuals involved in SARs who suffered serious harm and died

Inidividual involved in SARs who suffered serious harm and survived
|-
|Source of Risk
|The source of risk refers to the person who is suspected of carrying out abuse. If a concluded enquiry has determined that there is more than one source of risk, there should be a count for each source type in these tables
|Mandatory for Concluded Section 42 Enquiries, Optional / Voluntary for Other Concluded Enquires
|Service Provider

Other - Known to Individual

Other - Unknown to Individual
|-
|Type of Risk
|The type of risk describes the nature of the allegations made, such as physical or sexual. Multiple types of risk can be included in this table; please record one count for each different type and source.
|Mandatory for Section 42 enquires, Voluntary for Other enquires.
|Physical abuse

Sexual Abuse

Psychological abuse

Financial or material abuse

Discriminatory abuse

Organisational abuse

Neglect and acts of omission

Domestic abuse

Sexual exploitation

Modern slavery

Self-neglect
|} 

=== Contacts ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Child Unique ID
|Unique Identity number for each child.
|O
|
|-
|Age of Child (Years)
|Please provide the child's age in years at their last birthday. If a child is unborn, enter their age as '-1'.
|O
|
|-
|Date of Contact
|Provide the date the contact was received by the local authority. The date of birth should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Contact Source
|Identify the source of the contact using the following codes.
|O
|a) 1A: Individual
b) 1B: Individual

c) 1C: Individual

d) 1D: Individual

e) 2A: Schools

f) 2B: Education services

g) 3A: Health services

h) 3B: Health services

i) 3C: Health services

j) 3D: Health services

k) 3E: Health services

l) 3F: Health services

m) 4: Housing

n) 5A: LA services

o) 5B: LA services

p) 5C: LA services

p1) 5D: LA services

q) 6: Police

r) 7: Other legal agency

s) 8: Other

t) 9: Anonymous

u) 10: Unknown
|} 

=== Early help ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Assessment start date
|Please provide the date a child became subject to an early help assessment, a common assessment or targeted assessment. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number. As Early Help processes vary across local authorities, please provide the closest match to the request above by your authority for those children how were identified as needing an early help assessment or who were accessing early help services at the point of inspection.
|O
|
|-
|Assessment completion date
|Please provide the date an early help assessment, a common assessment or targeted assessment ended for the child. This may alternatively be the date the early help intervention was no longer in place. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number. As Early Help processes vary across local authorities, please provide the closest match to the request above by your authority for those children how were identified as needing an early help assessment or who were accessing early help services at the point of inspection. Where early help assessments are left blank due to a child continuing to access a service, please leave this blank.
|O
|
|} 

=== Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Date of referral
|Provide the date of this referral to children's social care services. A referral is defined as a request for services to be provided by local authority children's social care via the assessment process outlined in working together 2018. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Referral Source
|Identify the source of the contact using the following codes.
|O
|a) 1A: Individual

b) 1B: Individual

c) 1C: Individual

d) 1D: Individual

e) 2A: Schools

f) 2B: Education services

g) 3A: Health services

h) 3B: Health services

i) 3C: Health services

j) 3D: Health services

k) 3E: Health services

l) 3F: Health services

m) 4: Housing

n) 5A: LA services

o) 5B: LA services

p) 5C: LA services

p1) 5D: LA services

q) 6: Police

r) 7: Other legal agency

s) 8: Other

t) 9: Anonymous

u) 10: Unknown
|-
|Referral NFA
|The referral no further action flag allows the reporting of children who were referred but after initial consideration no further action was taken. Please indicate if the most recent referral (or individual referral) resulted in 'No Further Action' (NFA) by children's social care.
|O
|a) Yes

b) No
|-
|Number of Referrals in Last 12 Months
|Provide the number of referrals the child has received within the 12 months prior to their latest referral. The lowest value is therefore 0 where the referral had not followed one within 12 months. Please note: - this does not require the number in the previous 12 months for EACH referral, but the number in the 12 months before their LATEST referral. Therefore, where a child appears on this list multiple times, the number in this column will be the same in each case.
|O
|
|} 

=== Assessments ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Does the Child have a Disability
|Indicate if the child has a disability according to the Disability Discrimination Act 2005. This defines a disabled person as a person with a “physical or mental impairment which has a substantial and long-term adverse effect on his ability to carry out normal day-to-day activities.” 
|O
|
|-
|Continuous Assessment Start Date
|This is the date the continuous assessment started. This should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Continuous Assessment Date of Authorisation
|Provide the date on which the assessment was completed and authorised. If the Continuous assessment is not complete this should be left blank. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number. This date will be within the last six months.
|O
|
|-
|Was the child assessed as requiring LA children's social care support
|Please indicate if the assessment resulted in the child accessing a social care service. Where a child has not accessed a service, this will usually be where an assessment was closed and the child recorded as ‘RC8 - case closed after assessment, no further action’ or 'RC9 - case closed after assessment, referred to early help'. Please indicate if the assessment resulted in the child accessing a social care service. Where a child has not accessed a service, this will usually be where an assessment was closed and the child recorded as ‘RC8 - case closed after assessment, no further action’ or 'RC9 - case closed after assessment, referred to early help'. If the assessment is ongoing, please leave blank. 
|O
|a) Yes
b) No
|} 

=== Section 47 Enquiries and Initial Child Protection Conferences ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Strategy discussion initating Section 47 Enquiry Start Date
|This is the date of the strategy discussion that initiated the Section 47 Enquiry. Please enter the date of the strategy discussion at which the Section 47 enquiry was initiated. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Date of Initial Child Protection Conference
|Please enter the date on which the Initial Child Protection Conference took place (if applicable). If an ICPC has not yet taken place or was deemed unnecessary please leave blank. The due date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Number of Section 47 Enquiries in the last 12 months
|Provide the number of section 47 enquiries the child has been the subject of within the 12 months prior to their latest section 47 enquiry. The lowest value is therefore 0 where the section 47 has not followed one within 12 months. Please note: - This column asks for a figure based on the LATEST section 47 enquiry for that child. When a child appears on this list more than once, the number in this column will be the same in each row for that child.
|O
|
|-
|Number of ICPCs in the last 12 months
|Provide the number of initial child protection conferences the child has been the subject of in the 12 months before their latest Section 47 enquiry. The lowest value is therefore 0 when there has not been an ICPC within the 12 months of the latest S47. This is counting prior ICPCs, not whether the current S47 resulted in ICPC. Please note: - This column asks for a figure based on the LATEST section 47 enquiry for that child. When a child appears on this list more than once, the number in this column will be the same in each row for that child.
|O
|
|} 

=== Children in Need ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CIN Start Date
|Please enter the date the most recent episode of need commenced. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Primary Need Code
|Please enter the child's latest primary need for the latest Children in Need episode. It should not be left blank. Only one reason can be recorded. 
|O
|N1 - Abuse or neglect

N2 - Child's disability

N3 - Parental disability or illness

N4 - Family in acute stress

N5 - Family dysfunction

N6 - Socially unacceptable behaviour

N7 - Low income

N8 - Absent parenting

N9 - Cases other than children in need

N0 - Not stated
|-
|CIN Closure Date
|Enter the date the most recent child in need episode ceased. Please leave blank if the most recent episode is open. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Reason for Closure
|For cases that have ceased in the six months prior to inspection please enter the reason the most recent Children in Need episode ceased. Please use the reason for closure descriptors provided by the DfE in the latest CIN census guide. Please leave blank if the most recent episode is open.
|O
|RC1 - Adopted
RC2 - Died

RC3 - Child arrangements order

RC4 - Special guardianship order

RC5 - Transferred to services to another local authority

RC6 - Transferred to adult social care services

RC7 - Services ceased for any other reason, including child no longer in need

RC8 - Case closed after assessment, no further action

RC9 - Case closed after assessment, referred to early help
|-
|Case status
|Please indicate the current status of this child. Please only use one code below and take the first of the codes below that applies (unless closed). i.e. Where a child is already CIN and is subject to an open assessment, please record as CIN. Where a child is both CLA and CP, please record as CLA.
|O
|a) Looked after child
b) Child Protection plan

c) Child in need plan

d) Open assessment

e) Closed episode
|} 

=== Child Protection ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Child Protection Plan Start Date
|Please enter the start date of the Child Protection Plan. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Latest Category of Abuse
|Record the category of abuse most recently assigned to the child protection plan. The multiple category is for when more than one category of abuse is relevant to the child’s current protection plan. It is not for children who have been the subject of more than one child protection plan during the year.
|O
|a) Neglect

b) Physical abuse

c) Sexual abuse

d) Emotional abuse

e) Multiple/not recommended
|-
|Child Protection Plan End Date
|Please enter the date that the most recent child protection plan ceased. Please leave blank if the most recent plan is open. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Number of Previous Child Protection Plans
|The number of previous times that a child was made the subject of a child protection plan by the same local authority. If this is the first plan then the value should be zero. Child protection plans issued by other local authorities should not be counted. The number of previous child protection plans includes the number of times the child was on the child protection register. This column should not be blank as the minimum number is 0.
|O
|
|} 

=== Children in Care ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Unaccompanied Asylum Seeking Child (USAC) within the Last 12 Months (Y/N)
|Please indicate if a child is an unaccompanied asylum seeking child within the 12 months prior to inspection. An unaccompanied asylum seeking child is defined by paragraph 352ZD of the Immigration rules as one who is: • Under 18 years of age when the claim is submitted • Claiming in their own right • Separated from both parents and is not being cared for by an adult who in law or by custom has responsibility to do so The Unaccompanied Asylum Seeking status of a child will cease if the child is granted refugee status, Humanitarian Protection or UASC leave (discretionary leave for young people whose asylum claim) is refused.
|O
|a) Yes

b) No
|-
|Date Started to be Looked After
|Please provide the date that the child became looked after for the current period. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Child's Category of Need
|Please provide the child's current category of need description for their current episode.
|O
|N1 - Abuse or neglect

N2 - Child's disability

N3 - Parental illness or disability

N4 - Family in acute stress

N5 - Family dysfunction

N6 - Socially unacceptable behaviour

N7 - Low income

N8 - Absent parenting
|-
|Is this a second or subsequent period of being a Looked After Child within the last 12 months (Y/N)
|Indicate if the child has had a previous period of care in the 12 months prior to inspection.
|O
|a) Yes
b) No
|-
|Start date of current legal status
|Please provide the date the current legal status of the child began. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Child's Legal Status
|Indicate the current legal status of the child. Refer to latest SSDA903 guidance and use SSDA903 codes as applicable.
|O
|C1: ICO
C2: FCO

D1: Freeing order

E1: Placement order

V2: Single period under S20

L1: Police protection LA

L2: EPO

L3: Child assessment order

J1: Remanded to LA or youth detention

J2: LA accommodation under PACE

J3: Youth rehabilitation order

V3: Short term breaks, episodes recorded

V4: Short term breaks, agreements recorded
|-
|What is the permanence plan for this child?
|Please indicate what the current primary permanence plan is for the child. Where the child does not have a permanence plan agreed (such as recently entered care) please leave blank.
|O
|a) Return to family

b) Adoption

c) SGO/CAO

d) Supported living in the community

e) Long-term residential placement

f) Long-term fostering

g) other
|-
|Date of Last Health Assessment
|Please provide the date of the last health assessment for the child. The SSDA903 guidance confirms details of what constitutes a health assessment. Please note that we are asking for information on all looked after children as at the date of the inspection, not just those who have been looked after continuously for 12 months. If the child does not have a health assessment, please leave blank. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Date of Last Dental Check
|lease provide the date of the last dental check for the child. The SSDA903 guidance confirms details of what constitutes a dental check. Please note that we are asking for information on all looked after children as at the date of the inspection, not just those who have been looked after continuously for 12 months. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Date Ceased to be Looked After
|For children that have ceased to be looked after in the six months prior to inspection please provide the date that the child's last looked after episode ended. Leave blank if child is still being looked after. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number.
|O
|
|-
|Reason Ceased to be Looked After
|For children that have ceased to be looked after in the six months prior to inspection please provide the reason the child ceased to be looked after.
|O
|a) E11: Adopted - application unopposed

b) E12: Adopted - consent dispensed

c) E2: Died

d) E3: Care taken by another LA

e) E4A: Returned home to live with parents or relatives - part of planning

f) E4B: Returned home to live with parents or relatives - not part of planning

g) E13: Parents, relatives or other with no parental responsibility

h) E41: residence order granted

i) E45: Special Guardianship Orders - former carer relative/friend

j) E46: Special Guardianship Orders - former carer other

k) E47: Special Guardianship Orders - relative/friend

l) E48: Special Guardianship Orders - other

m) E5: Moved to independent living - supported

n) E6: Moved into independent living - no support

o) E7: Transferred to residential care funded by adult social services

p) E9: Sentenced to custody

q) E14: Accommodation on remand ended

r) E15: Age assessment determined child was 18 or over

s) E16: Child moved abroad

t) E8: Care ceased for any other reason

u) X1: CodeError

v) E17: Aged 18+ and remained with current carers
|-
|Start Date of Most Recent Placement
|Please provide the date that the child started in their most recent placement.
|O
|
|-
|Placement Type
|Please provide the placement type descriptor for the child's most recent placement. Published guidance by the DfE provides greater detail on what is included within each specific code
|O
|a) U1: Foster placement - relative - long term

b) U2: Foster placement - relative - FFA

c) U3: Foster placement - relative - not FFA

d) U4: Foster placement - long term

e) U5: Foster placement - FFA

f) U6: Foster placement - not FFA

g) A3: Placed for adoption - consent - current foster

h) A4: Placed for adoption - consent - not foster

i) A5: Placed for adoption - order - foster

j) A6: Placed for adoption - order - not foster

k) P1: Placed with parents

l) P2: Independent living

m) P3: Residential employment

n) H5: Residential accommodation

o) K1: Secure Children’s Homes

p) K2: Children’s Homes

q) R1: Residential Care Home

r) R2: NHS/Health Trust

s) R3: Family Centre or Mother and Baby Unit

t) R5: Young Offender Institution

u) S1: Residential school

v) Z1: Other placements

w) T0: Temporary placement

x) T1: Temporary placement - hospital

y) T2: Temporary placement - holiday

z) T3: Temporary placement - carer holiday

zz) T4: Temporary placement - seven days or less
|-
|Placement postcode
|Please provide the postcode of the establishment/provider. For fostering placements please provide the postcode of the actual foster carer rather than of the fostering agency. 
|O
|
|} 

=== Leaving Care Services ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Unaccompanied Asylum Seeking Child (USAC), or formerly UASC if 18 or over (Y/N)
|Please indicate if a child is either an unaccompanied asylum seeking child within the 12 months prior to inspection, or if they are 18 or over, if they were UASC prior to turning 18.
|O
|a) Yes
b) No
|-
|LA In Touch
|Please confirm whether the LA is currently in touch with the care leaver. This should be the most recent record available which may or may not be the birthday window.
|O
|a) Yes
b) No

c) Died

d) Refu

e) NREQ

f) Rhom
|-
|Latest Date of Contact
|This should be the latest date of PA contact with the young person. This may differ by Local Authority as to what dates are available, so please advise in the comments column as to what contact types are included. The date should be recorded in a DD/MM/YYYY format, i.e. day/month/year as a four digit number. Leave blank if you are not in touch with the care leaver.
|O
|
|-
|Type of Accommodation
|Please provide the description (using the SSDA903 codes) for the type of accommodation that most accurately reflects the young person's current circumstances. Leave blank if you are not in touch with the care leaver.
|O
|B: Parents/relatives
C: Community home / residential care

D: Semi-independent, transitional accommodation and self-contained accommodation

E: Supported lodgings

G: Abroad

H: Deported

K: Ordinary lodgings, without formal support

R: Residence not known

S: No fixed abode / homeless

T: Foyers and similar supported accommodation

U: Independent living

V: Emergency accommodation

W: Bed and breakfast

X: In custody

Y: Other accommodation

Z: With former foster carers
|-
|Activity Status
|Indicate the activity status of the care leaver using the code that most accurately reflects the young person's current activity. Leave blank if you are not in touch with the care leaver.
|O
|F1: Full time in higher education
P1: Part time in higher education

F2: Full time in eductation other than higher

P2: Part time in education other than higher

F4: Young person engaged full time in an apprenticeship

P4: Young person engaged part time in an apprenticeship

F5: Young person engaged full time in training or employment (not apprenticeship)

P5: Young person engaged part time in training or employment (not apprenticeship)

G4: Not in education, employment or training - illness or disability

G5: Not in education, employment or training - other

G6: Not in education, employment or training - pregnancy or parenting
|} 

=== Community Data Items ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Client stated sex – SEX
|
|O
|
|-
|Country of birth – NATION
|Country of birth, code selected from ISO 3166-1 alpha-3 standard. ISO 3166 Country Codes - www.iso.org/iso/country_codes To view list of codes, select the link to the Online Browsing Platform and refer to Alpha 3 codes. New permissible value added in core dataset H of ‘Z – Not stated’
|O
|
|-
|Agency codes – AGNCY
|Each treatment provider or secure setting establishment is assigned with an agency code. Responsibility for allocating a code is that of the relevant regional NDTMS manager. A general guideline is that the code should comprise of 2 parts. 1. A letter or letters which is intended to indicate the NDTMS region which ‘manages’ that treatment provider or secure setting establishment. 2. An identifier (1 to 6 alphanumeric characters) which uniquely identifies that treatment provider within the region. This guideline will ensure uniqueness of the agency code on a national basis. Examples of agency codes include L0043, W1000 and U0001.
|O
|
|-
|Consent for NDTMS – CONSENT
|
|O
|N - No client has not consented
Y - Yes client has consented
|-
|Client participating in IPS (individual placement and support) – IPSCLIENT
|
|O
|N - No
Y - Yes
|-
|Consent for IPS – IPSCONSENT
|A client can consent to share their data with NDTMS and not consent to providing data to the IPS scheme.
|O
|N - No - IPS client has not consented
Y - Yes - IPS client has consented
|-
|Full postcode of residence (IPS)
|IPS full postcode is used to establish/validate the geographic areas in which a client is resident. Full postcodes should only be submitted if the client has given IPS consent and must be separated by a space (for example, NW7 3AB) Default post code for clients with No fixed abode is ZZ99 3VZ.
|O
|
|-
|Postcode – PC
|Postcode mappings are used to establish/validate the geographic areas in which a client is resident. Only partial postcodes should be submitted and must be separated by a space (for example, NW7 3) Default post code for clients with no fixed abode is ZZ99 3VZ (submitted partially as ZZ99 3).
|O
|
|-
|DAT of residence – DAT
|A list of the partnership and DAT codes currently used for NDTMS is given in the NDTMS Geographic Information document:
www.gov.uk/government/publications/geographic-information-for-the-national-drug-treatment-monitoring-system
|O
|
|-
|Local authority – LA
|A list of local authority codes currently used for NDTMS is given in the NDTMS Geographic Information document:
www.gov.uk/government/publications/geographic-information-for-the-national-drug-treatment-monitoring-system
|O
|
|-
|Upper tier local authority – UTLA
|A list of upper tier local authority codes to be used for NDTMS is given in the NDTMS Geographic Information document:
www.gov.uk/government/publications/geographic-information-for-the-national-drug-treatment-monitoring-system
|O
|
|-
|Lower tier local authority – LTLA
|A list of lower tier local authority codes to be used for NDTMS is given in the NDTMS Geographic Information document:
www.gov.uk/government/publications/geographic-information-for-the-national-drug-treatment-monitoring-system
|O
|
|-
|Referral source – RFLS
|
|O
|4 - Self

69 - Self-referred via health professional

37 - Relative/peer/concerned other

3 - GP

63 - Arrest referral

70 - Community Rehabilitation Company (CRC)

6 - DRR

71 - National Probation Service

72 - Liaison and Diversion

19 - Adult social care services

74 - Domestic abuse service

59 - Employment/education service

10 - Syringe exchange

13 - Prison

22 - Hospital

76 - Hospital alcohol (including A and E departments)

77 - Housing/homelessness service

36 - Outreach

56 - Employer

57 - ATR

75 - Recommissioning transfer

15 - Other

30 - Children and family services

33 - Universal education

34 - Alternative education

35 - Targeted youth support

38 - Adult mental health services

49 - Primary care

28 - Including child and adolescent mental health

services.

50 - School nurse

39 - Adult treatment provider

40 - Young people’s structured treatment provider

41 - Non-structured treatment substance misuse services

61 - Children and YP secure estate

43 - Crime prevention

45 - YOT

47 - Post custody

78 - Helpline/website

55 - YP housing
|-
|Previously treated – PREVTR
|
|O
|N - No

Y - Yes
|-
|TOP care coordination – TOPCC
|
|O
|N - No

Y - Yes
|-
|Client stated sexual orientation – SEXUALO
|Person asked but declined to provide a response
Not recorded - service unable to obtain information
|O
|1 - Heterosexual or Straight
2 - Gay or Lesbian

3 - Bisexual

U - Person asked ans does not know or is not sure

Z - Not stated

4 - Other sexual orientation not listed

9 - Not known
|-
|Pregnant – PREGNANT
|Only expected for females
|O
|N - No
Y - Yes
|-
|Religion – RELIGION
|
|O
|A - Baha'i
B - Buddhist

C - Christian

D - Hindu

E - Jain

F - Jewish

G - Muslim

H - Pagan

I - Sikh

J - Zoroastrian

K - Other

L - None

M - Declines to disclose

N - Unknown
|-
|Disability (Disability No 1, No 2, No 3) – DISABLE1, DISABLE2, DISABLE3
|
|O
|1 - Behaviour and emotional
2 - Hearing

3 - Manual dexterity

4 - Learning disability

5 - Mobility and gross motor

6 - Perception of physical danger

7 - Personal, self-care and continence

8 - Progressive conditions and physical health

9 - Sight

10 - Speech

11 - Special educational needs

XX - Other

NN - No disability

ZZ - Not stated
|-
|What is the client’s current housing situation? – HOUSING
|
|O
|1 - Owns home
2 - Rented home only – self-contained – rents from a private landlord

3 - Rented home only – self-contained - rents from a social landlord (local authority or housing

association)

4 - Rented home only – shares facilities - rents from a private landlord

5 - Rented home only – shares facilities - rents from a social landlord (local authority or housing association)

6 - Other – university or college accommodation

7 - Other – living with friends permanently

8 - Other – living with family permanently

9 - Other – supported accommodation

10 - Other – healthcare setting

11 - Other – accommodation tied to job (including Armed Forces)

12 - Other – approved premises

13 - Other – authorised Gypsy and Traveller site

14 - No home of their own – living with friends as a short-term guest

15 - No home of their own – living with family as a shortterm gues

16 - No home of their own – sofa surfing (sleeps on different friends’ floor or sofa each night)

17 - No home of their own – lives on the streets/rough sleeping

18 - No home of their own – squatting

19 - No home of their own –night/winter shelter

20 - No home of their own – bed and breakfast, or other hotel

21 - No home of their own – hostel

22 - No home of their own – supported accommodation

23 - No home of their own –temporary housing

24 - No home of their own –unauthorised Gypsy and Traveller encampment
|-
|Is the client threatened with homelessness in the next 56 days (8 weeks)?
|
|O
|N - No
Y - Yes
|-
|Accommodation need – ACCMNEED
|
|O
|26 - YP living with relative
27 - Independent YP - settled accommodation

28 - Client living independently in unsettled accommodation

29 - Client living independently with no fixed Abode

31 - Client living in specifically commissioned housing

33 - Client has been placed in care, such as

children’s homes, foster care for looked

after child

34 - Client has been placed in a secure setting for example, a young offender institution (YOI), a secure training centre or a secure ch
|-
|Employment status – EMPSTAT
|
|O
|1 -
2 - Undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training as a student and not working or actively seeking work

9 - Long-term sick or disabled, those receiving government sickness and disability benefits

10 - Looking after the family or home as a homemaker and not working or actively seeking work

12 - Unemployed and actively seeking work

13 - Not receiving government sickness and disability benefits and not working or actively seeking work

14 - Unemployed and actively seeking work

15 - Retired

16 - Expansion of unemployed, for instancethose who are not working or actively seeking work

99 - Client asked but declines to answer

5 - N/A

6 - N/A
|-
|Time since last paid employment – TSLPE
|
|O
|0 - Less than one year since paid employment
1 - Between 1 and 2 years since last paid employment

2 - Between 2 and 3 years since last paid employment

''n*'' - n is defined as an integer between 3 and75. Number of years should be rounded down, for example if a person was last in employment 3.6 years ago enter 3

97 - Client has never been in paid employment

99 - N/A
|-
|British Armed Forces veteran – VETERAN
|
|O
|Y
N

Z
|-
|Parental responsibility for children under 18 – PARENT
|
|O
|Y - Yes
N - No

Z - Z
|-
|If client has parental responsibility, do any of these children live with the client? – PRNTSTAT
|
|O
|11 - All the children live with client
12 - Some of the children live with client

13 - None of the children live with client

15 - Client declined to answer
|-
|Children under 18 living with client – CHILDWTH
|
|O
|0 - No children living with
1 - 1 child living with client

2 - 2 children living with client

''n*'' - n children living with client

98 - Client declined to answer

99 - Undisclosed number
|-
|If client has parental responsibility and/or children living with them, what help are the children receiving? (1) – EHCSC
|
|O
|1 - Early Help (family support)
2 - Child in need (LA service)

3 - Has a Child Protection Plan (LA service)

4 - Looked after child (LA service)

5 - None of the children are receiving any help

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|What help are the children for which the client has parental responsibility and/or children living with the client receiving? (2) & (3) – EHCSC2 and EHCSC3
|
|O
|1 - Early Help (family support)
2 - Child in need (LA service)

3 - Has a child protection plan(LA service)

4 - Looked after child (LA service)

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|Has the client ever been the victim of domestic abuse? – DOMVIC
|
|O
|1 - Yes – currently (last 28 days)
2 - Yes – previously

3 - Yes – currently and previously

4 - No

5 - Client declined to answer

6 - Not appropriate to ask
|-
|Has the client ever abused someone close to them? – DOMPER
|
|O
|1 - Yes – currently (last 28 days)
2 - Yes – previously

3 - Yes – currently and previously

4 - No

5 - Client declined to answer

6 - Not appropriate to ask
|-
|Has the client ever received money or goods in exchange for sex? – SEXWORK
|
|O
|A - Yes – in the past year
B - Yes – but not in the past year

C - No

Z - Client declined to answer
|-
|Drug list (problem substance No 1, No 2, No 3) – DRUG1, DRUG2, DRUG3
|
|O
|
|-
|Injecting status – INJSTAT
|
|O
|P - Previously injected (but not currently)
C - Currently injecting

N - Never injected

Z - Client declined to answer
|-
|What is the client’s SADQ Score? – SADQ
|
|O
|0 to 60 - The client’s SADQ score
98 - Information not available

99 - Client declined to answer
|-
|Hep B intervention status – HEPBSTAT
|
|O
|B - Offered and refused
C - Immunised already

D - Not offered

F - Assessed as not appropriate to offer

G - Offered and accepted – not yet had any vaccinations

H - Offered and accepted – started having vaccinations

I - Offered and accepted – completed vaccination course

K - Deferred due to clinical reasons
|-
|Hep C intervention status – HEPCSTAT
|
|O
|B - Offered and refused
D - Not offered

F - Assessed as not appropriate to offer

G - Offered and accepted – not yet had a test

H - Offered and accepted – had a hep C test

K - Deferred due to clinical reasons
|-
|Hep C test result antibody status – HCVAS
|
|O
|1 - Positive

2 - Negative

3 - Unknown
|-
|Hep C test result PCR (RNA) status – HCVPCR
|
|O
|1 - Positive

2 - Negative (never infected)

3 - Unknown

4 - Negative (cleared by treatment)

5 - Negative (cleared naturally)
|-
|Is client HIV positive? – HIVSTAT
|
|O
|Y - Yes
N - No

U - Unknown

Z - Client declined to answer
|-
|Referral for alcohol related liver disease – LIVSCRN
|
|O
|Y - Yes
N - No

U - Unknown
|-
|Has the client been issued with naloxone at episode start? – NALOXISS
|
|O
|1 - Yes – nasal naloxone

2 - Yes – injectable naloxone

3 - Yes – both nasal and injectable naloxone

4 - No – client already in possession of adequate naloxone

5 - No – assessed as not appropriate

6 - No – service does not provide naloxone

7 - Yes – not yet issued

8 - No – offered and refused
|-
|Has the client ever been administered with naloxone to reverse the effects of an overdose? – NALOXAD
|
|O
|Y - Yes

N - No

U - Unknown

Z - Client declined to answer
|-
|Does the client have a mental health treatment need – MTHTN
|
|O
|Y - Yes

N - No

Z - Client declined to answer
|-
|Is the client receiving treatment for their mental health need(s)? (1) – CRTMHN
|
|O
|1 - Already engaged with the community mental health team/other mental health services

2 - Engaged with Improved Access to Psychological Therapy (IAPT)

3 - Receiving mental health treatment from GP

4 - Receiving any NICE-recommended psychosocial or pharmacological intervention provided for the treatment of a mental health problem in drug or alcohol services

5 - Has an identified space in a health-based place of safety for mental health crises

6 - Treatment need identified but no treatment being received

99 - Client declined to commence treatment for their mental health need
|-
|Is the client receiving treatment for their mental health need(s) (2) & (3) – CRTMHN2 & CRTMHN3
|
|O
|1 - Already engaged with the community mental health team/other mental health services
2 - Engaged with Improved Access to Psychological Therapy (IAPT)

3 - Receiving mental health treatment from GP

4 - Receiving any NICE recommended psychosocial or pharmacological intervention provided for the treatment of a mental health problem in drug or alcohol services

5 - Has an identified space in a health-based place of safety for mental health crises
|-
|What was the care status of the YP at treatment start? – YPLCS
|
|O
|2 - Not a looked after child or child in need

1 - Looked after child

3 - Child in need
|-
|Has the YP been sexually exploited prior to treatment start? – YPSSEXEX
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Has the YP self-harmed prior to treatment start? – YPSSLFHM
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Has YP been involved in antisocial behaviour or committed a criminal act on more than 1 occasion in the past 6 months? – YPABACF
|
|O
|N - No

Y - Yes
|-
|YP’s education/employment/training status at treatment start – YPSESTAT
|
|O
|1 - Mainstream education
2 - Alternative education

3 - Temporarily excluded

4 - Permanently excluded

5 - Persistent absentee

6 - Apprenticeship or training

10 - Economically inactive caring role

11 - Economically inactive health issue

12 - Voluntary work

13 - Regular employment

14 - Not in employment or education or training (NEET)

Z - Client declined to answer
|-
|YP registered with GP at treatment start? – YPSGP
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|YP engaged in unsafe sex prior to treatment start? – YPSUSS
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Has the YP been offered a screen for sexually transmitted infections (including chlamydia)? – YPSSTICH
|
|O
|A - Offered and accepted
B - Offered and refused

D - Assessed as not appropriate to offer
|-
|Was the YP subject to a Child Protection Plan (CPP) at treatment start? – YPCPL
|
|O
|1 - Is currently subject to Child Protection Plan (CPP)
3 - Has never been subject to Child Protection Plan (CPP)

4 - Has previously been subject to a Child Protection Plan (CPP)
|-
|Has the YP been involved in gangs at treatment start? – YPGANGS
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Has the YP been affected by child criminal exploitation at treatment start? – YPCRIMEX
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Does the young person feel affected by substance misuse in their close family/members of their household at treatment start? – YPASMFM
|
|O
|N - No

Y - Yes
|-
|YP met goals agreed on care plan at discharge – YPECAREP
|
|O
|N - No

Y - Yes
|-
|YP offered continuing support from non-substance misuse services at discharge – YPCSNSM
|
|O
|2 - No

1 - Yes

3 - No further support required
|-
|Discharge Reason – DISRSN
|
|O
|80 - Treatment completed – drug-free
81 - Treatment completed – alcohol-free

82 - Treatment completed – occasional user (not opiates or crack)

83 - Transferred – not in custody

84 - Transferred – in custody

74 - Transferred – recommissioning transfer

71 - Incomplete – onward referral offered and refused

85 - Incomplete – dropped out

86 - Incomplete – treatment withdrawn by provider

87 - Incomplete – retained in custody

88 - Incomplete – treatment commencement declined by client

89 - Incomplete – client died

93 - Transferred – programme completed at the residential provider – additional residential treatment required

94 - Transferred – programme completed at the residential provider – additional community treatment required

95 - Transferred – programme not completed at the residential provider – additional

residential treatment required

96 - Transferred – programme not completed at the residential provider – additional community treatment required

97 - Transferred – transition to adult substance misuse service
|-
|Has the client been referred for hep C treatment – REFHEPCTX
|
|O
|N - No

Y - Yes
|-
|Treatment interventions – MODAL
|
|O
|94 - Pharmacological intervention
95 - Psychosocial intervention

96 - Recovery support

98 - YP pharmacological

102 - YP psychosocial

101 - YP multi agency working

52 - YP harm reduction service

111 - IPS (Individual Placement & Support)

113 - ADDER support

114 - Accelerator support

117 - RSDATG engagement

103 - Benzodiazepines detoxification

104 - Lofexidine

105 - Naltrexone

106 - Opioid re-induction

107 - Opioid reduction – methadone

108 - Opioid reduction –buprenorphine

116 - Opioid reduction –buprenorphine depot injection (e.g. Buvidal)

109 - Opioid maintenance –methadone

110 - Opioid maintenance –buprenorphine

115 - Opioid maintenance –buprenorphine depot injection (e.g. Buvidal)

84 - Psychosocial intervention mental disorder

85 - Other structured psychosocial intervention

5 - Structured day programme

12 - Other structured intervention

77 - Alcohol prescribing

76 - Alcohol brief intervention

52 - YP harm reduction (specialist)

56 - YP specialist pharmacological intervention

63 - YP psychosocial –counselling

64 - YP psychosocial –cognitive behavioural therapy

65 - YP psychosocial –motivational interviewing

66 - YP psychosocial – relapse prevention

67 - YP psychosocial – family work
|-
|Intervention setting – MODSET
|
|O
|1 - Community
2 - Inpatient unit

3 - Primary care

4 - Secure setting

5 - Residential

6 - Recovery house

13 - YP community

7 - YP inpatient unit – substance misuse specific

8 - YP inpatient unit – not substance misuse specific

9 - YP residential unit – substance misuse specific

11 - YP residential unit – not substance misuse specific

10 - YP home

12 - YP secure estate

14 - YP primary care
|-
|Proportion of face-to-face appointments with the keyworker – SUBPROPFTF
|
|O
|A - All face-to-face
B - Mostly face-to-face

C - Equal mix of face-to-face and digital

D - Mostly digital

E - All digital
|-
|Adult pharmacological prescribing sub interventions Methadone (oral solution) * – Opioid assessment and stabilisation – PHMETSTBL
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Methadone (oral solution) * – Opioid withdrawal – PHMETWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Methadone (oral solution) * – Opioid maintenance – PHMETMAIN
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Current daily dose of liquid oral methadone medication *(ml) – PHDOSMET
|Number of millilitres (ml) of liquid methadone solution Field should be completed at SIR if treatmentintervention is/was pharmacological
|O
|
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) # – Opioid assessment and stabilisation – PHBUPSTBL
|Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) # – Opioid withdrawal – PHBUPWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) # – Opioid maintenance – PHBUPMAIN
|Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) with Naloxone # – Opioid assessment and stabilisation – PHBUNASTBL
|Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) with Naloxone # - Opioid withdrawal – PHBUNAWTH
|Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine (tablet/wafer) with Naloxone # - Opioid maintenance – PHBUNAMAIN
|Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Current daily dose of oral buprenorphine medication #(mg) – PHDOSBUP
|Number of milligrams (mg) of oral buprenorphine solution Field should be completed at SIR if treatment intervention is/was pharmacological
|O
|0 to 99
|-
|Adult pharmacological prescribing sub interventions Is consumption of opioid substitution therapy (OST) medication currently supervised – PHOSTSPVD
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|1 - Supervised

2 - Unsupervised

99 - Not applicable
|-
|Adult pharmacological prescribing sub interventions Buprenorphine depot injection (rods or fluid) – Opioid withdrawal – PHBUDIWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Buprenorphine depot injection (rods or fluid) – Opioid maintenance – PHBUDIMAIN
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Diamorphine injection – Opioid assessment and stabilisation/withdrawal/maintenance – PHDIAINJ
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Methadone injection – Opioid assessment and stabilisation/withdrawal/maintenance – PHMETHINJ
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Benzodiazepine – Benzodiazepine maintenance – PHBENMAIN
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Benzodiazepine – Stimulant withdrawal – PHBENSWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Benzodiazepine – GHB/GBL withdrawal – PHBENGWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Stimulant (for example, dexamphetamine) – Stimulant withdrawal – PHSTIMWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Pregabalin – Gabapentinoid withdrawal – PHPREGWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Gabapentin – Gabapentinoid withdrawal – PHGABAWTH
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Naltrexone (oral) – Opioid relapse prevention – PHNALTRLPR
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Naltrexone (oral) – Alcohol relapse prevention/consumption reduction – PHNALTALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Chlordiazepoxide – Alcohol withdrawal – PHCHLORALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Diazepam – Alcohol withdrawal – PHDIAALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Carbamazepine – Alcohol withdrawal – PHCARBALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Other prescribed medication for alcohol withdrawal – PHOTHALCW
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Acamprosate – Alcohol relapse prevention – PHACAMALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Disulfiram – Alcohol relapse prevention – PHDISUALC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Vitamin B and C supplement to prevent/treat Wernicke’s encephalopathy/Wernicke-Korsakoffs – PHVITBC
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult pharmacological prescribing sub interventions Any other medication for the treatment of drug misuse/dependence/withdrawal/ associated symptoms – PHOTHMED
|Field should be completed at SIR if treatment
intervention is/was pharmacological
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved in motivational interventions – PSYMOTI
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved with contingency management (drug focused) – PSYCNMG
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventionsed with family and social network interventions – PSYFSNI
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Evidence-based psychological interventions for co-existing mental health disorders –PSYMNTH
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved with psychodynamic therapy – PSYDNMC
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved with 12-step work – PSYSTP
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved in counselling – BACP accredited – PSYCOUN
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult psychosocial sub interventions Client involved with cognitive and behavioural based relapse prevention interventions (substance misuse specific) – PSYCGBH
|Field should be completed at SIR if treatment intervention is/was psychosocial
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with peer support involvement – RECPEER
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with facilitated access to mutual aid – RECMAID
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with family support – RECFMSP
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with parenting support – RECPRNT
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with housing support – RECHSE
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with employment support – RECEMP
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with education and training support – RECEDUT
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with supported work projects – RECWPRJ
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with recovery check-ups – RECCHKP
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with evidence-based psychosocial interventions to support relapse prevention – RECRLPP
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with complementary therapies – RECCMPT
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with mental health interventions – RECGNH
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with smoking cessation interventions – RECSMOC
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with domestic abuse support for victim/survivor – RECDOMVIC
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided witH domestic abuse support for perpetrator – RECDOMPER
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|Adult recovery support sub interventions Client provided with prescribing for relapse prevention (post structured treatment only) – RECMEDRLP
|Field should be completed at SIR if treatment intervention is/was recovery support
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with cognitive and behavioural interventions – CBIYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with motivational interventions – MIYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with structured family interventions (including family therapy) –SFIFTYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with multi component programmes – MCPYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with contingency management – CMYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP psychosocial sub interventions Client provided with counselling – CYPS
|Field should be completed at SIR if intervention is/was YP psychosocial
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Education/training – YPEDTR
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Employment/volunteering – YPEVOL
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Housing – YPINHOU
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Generic family support – YPRGFS
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Generic parenting support – YPGPS
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Peer support involvement/mentoring – YPPSIM
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Mental health – YPMHLTH
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Offending – YPOFFND
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Health – YPHEALTH
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Sexual health/pregnancy – YPSHP
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Meaningful activity – YPMATY
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Disability services – YPDISSER
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Behavioural services – YPBESER
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Young carers – YPYCAR
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Smoking cessation – YPSCES
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions services (including targeted youth support) – YPSER
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Children’s social care – YPCSC
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Client provided with domestic abuse support for victim/survivor – RECDOMVIC
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|YP multi agency working sub interventions Client provided with domestic abuse support for perpetrator – RECDOMPER
|Field should be completed at SIR if treatment intervention is/was multi-agency working
|O
|N - No

Y - Yes
|-
|CIR Stage – CIRSTAGE
|
|O
|1 - Partial CIR
2 - Full CIR
|-
|CIR Hep B intervention status – CIRHEPBSTAT
|
|O
|B - Offered and refused
C - Immunised already

D - Not offered

F - Assessed as not appropriate to offer

G - Offered and accepted – not yet had any vaccinations

H - Offered and accepted – started having vaccinations

I - Offered and accepted – completed vaccination course

K - Deferred due to clinical reasons
|-
|CIR Hep C intervention status – CIRHEPCSTAT
|
|O
|B - Offered and refused
D - Not offered

F - Assessed as not appropriate to offer

G - Offered and accepted – not yet had a test

H - Offered and accepted – had a Hep C test

K - Deferred due to clinical reasons
|-
|CIR Hep C test result antibody status – CIRHCVAS
|
|O
|1 - Positive
2 - Negative

3 - Unknown
|-
|CIR Hep C test result PCR (RNA) status – CIRHCVPCR
|
|O
|1 - Positive
2 - Negative (never infected)

3 - Unknown

4 - Negative (cleared by treatment)

5 - Negative (cleared naturally)
|-
|CIR Has the client been referred for Hep C treatment – CIRREFHEPCTX
|
|O
|N - No

Y - Yes
|-
|CIR Is client HIV positive? – CIRHIVSTAT
|
|O
|Y - Yes

N - No

U - Unknown

Z - Client declined to answer
|-
|CIR Referral for alcohol related liver disease – CIRLIVSCRN
|
|O
|Y - Yes

N - No

U - Unknown
|-
|CIR Has the client been issued with naloxone in the last 6 months? – CIRNALOXISS
|
|O
|1 - Yes – nasal naloxone
2 - Yes – injectable naloxone

3 - Yes – both nasal and injectable naloxone

4 - No – client already in possession of adequate naloxone

5 - No – assessed as not appropriate

6 - No – service does not provide naloxone

7 - Yes - not yet issued

8 - No - offered and refused
|-
|CIR Has the client been administered with naloxone to reverse the effects of an overdose in the last 6 months? - CIRNALOXAD
|
|O
|Y - Yes

N - No

U - Unknown

Z - Client declined to answer
|-
|CIR pregnant – CIRPREGNANT
|
|O
|Y - Yes

N - No
|-
|CIR Parental responsibility for children under 18 – CIRPARENT
|
|O
|Y - Yes

N - No

Z - Client declined to answer
|-
|CIR If client has parental responsibility, do any of these children live with the client? – CIRPRTST
|
|O
|11 - All the children live with client
12 - Some of the children live with client

13 - None of the children live with client

15 - Client declined to answer
|-
|CIR Children under 18 living with client – CIRCLDWT
|
|O
|0 - No children living with client
1 - 1 child living with client

2 - 2 children living with client

''n*'' - n children living with client

98 - Client declined to answer

99 - Undisclosed number
|-
|CIR If client has parental responsibility and/or children living with them, what help are the children receiving? (1) – CIREHCSC
|
|O
|1 - Early Help (family support)
2 - Child in need (LA service)

3 - Has a child protection plan (LA service)

4 - Looked after child (LA service)

5 - None of the children are receiving any help

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|CIR If client has parental responsibility and/or children living with them, what help are the children receiving? (2) & (3) – CIREHCSC2 & CIREHCSC3
|
|O
|1 - Early Help (family support)

2 - Child in need (LA service)

3 - Has a child protection plan (LA service)

4 - Looked after child (LA service)

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|CIR Has the client ever been the victim of domestic abuse? – CIRDOMVIC
|
|O
|1 - Yes – currently (last 28 days)
2 - Yes - previously

3 - Yes – currently and previously

4 - No

5 - Client declined to answer

6 - Not appropriate to ask
|-
|CIR Has the client ever abused someone close to them? – CIRDOMPER
|
|O
|1 - Yes – currently (last 28 days)
2 - Yes - previously

3 - Yes – currently and previously

4 - No

5 - Client declined to answer

6 - Not appropriate to ask
|-
|CIR What is the client’s current housing situation? – CIRHOUSING
|
|O
|1 - Owns home

2 - Rented home only –self-contained - rents from a private landlord

3 - Rented home only –self-contained - rents from a social landlord (local authority or housing association)

4 - Rented home only –shares facilities -rents from a private landlord

5 - Rented home only –shares facilities -rents from a social landlord (local authority or housing association)

6 - Other - university or college accommodation

7 - Other - living with friends permanently

8 - Other - living with family permanently

9 - Other - supported accommodation

10 - Other - health care setting

11 - Other -accommodation tied to job (including Armed Forces)

12 - Other - approved premises

13 - Other - authorised Gypsy and Traveller site

14 - No home of their own - living with friends as a short-term guest

15 - No home of their own - living with family as a short-term guest

16 - No home of their own - sofa surfing (sleeps on different friends’ floor or sofa each night)

17 - No home of their own - lives on the streets/rough sleeping

18 - No home of their own – squatting

19 - No home of their own – night/winter shelter

20 - No home of their own – bed and breakfast, or other hotel

21 - No home of their own – hostel

22 - No home of their own – supported accommodation

23 - No home of their own – temporary housing

24 - No home of their own – unauthorised Gypsy and Traveller encampment
|-
|CIR Is the client threatened with homelessness in the next 56 days (8 weeks)? – CIRHOMELESS
|
|O
|N - No

Y - Yes
|-
|CIR Does the client have a mental health treatment need? – CIRMTHTN
|
|O
|N - No
Y - Yes

Z - Client declined to answer
|-
|CIR Is the client currently receiving treatment for their mental health need(s)? (1) – CIRCRTMHN
|
|O
|1 - Already engaged with the community mental health team/Other mental health services

2 - Engaged with Improved Access to Psychological Therapy (IAPT)

3 - Receiving mental health treatment from GP

4 - Receiving any NICE - recommended psychosocial or pharmacological intervention provided for the treatment of a mental health problem in drug or alcohol services

5 - Has an identified space in a health-based place of safety or mental health crises

6 - Treatment need identified but no treatment being received

99 - Client declined to commence treatment for their mental health need
|-
|CIR Is the client currently receiving treatment for their mental health need(s)? (2) & (3) – CIRCRTMHN2 & CIRCRTMHN3
|
|O
|1 - Already engaged with the community mental health team/Other mental health services

2 - Engaged with Improved Access to Psychological Therapy (IAPT)

3 - Receiving mental health treatment from GP

4 - Receiving any NICE - recommended psychosocial or pharmacological interventionprovidedfor the treatment of a mental health problem in drug or alcohol

services

5 - Has an identified space in a health-based place of safety for mental health crises
|-
|CIR Is the YP subject to a child protection plan (CPP)? – CIRYPCPL
|
|O
|1 - Is currently subject to child protection plan (CPP)

2 - Has never been subject to child protection plan (CPP)

3 - Has previously been subject to a child protection plan (CPP)
|-
|CIR Has the YP been offered a screen for sexually transmitted infections (including chlamydia)? – CIRYPSSTICH
|
|O
|A - Offered and accepted

B - Offered and refused

D - Assessed as not appropriate to offer
|} 

=== Secure Setting Data Items ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Postcode mappings – PC
|Postcode mappings are used to establish/validate the geographic areas in which a client is resident. Only partial postcodes should be submitted and must be separated by a space (for example, NW7 3).
Default post code for clients with No fixed abode is ZZ99 3VZ (submitted partially as ZZ99 3).
|O
|
|-
|Transferred from – PRISON
|Only applicable to the secure settings dataset. Please note, this list will change periodically as secure settings are recommissioned.
Please contact your local NDTMS team for an up to date list.
|O
|
|-
|What was the client’s housing situation in the 28 days prior to custody? – HOUSING
|
|O
|1 - Owns home
2 - Rented home only – self - contained - rents from a private landlord

3 - Rented home only – self - contained - rents from a social landlord (local authority or housing association)

4 - Rented home only –shares facilities - rents from a private landlord

5 - Rented home only –shares facilities – rents from a social landlord (local authority or housing association)

6 - Other – university or college accommodation

7 - Other – living with friends permanently

8 - Other – living with family permanently

9 - Other – supported accommodation

10 - Other – health care setting

11 - Other – accommodation tied to job (including Armed Forces)

12 - Other – approved premises

13 - Other – authorised Gypsy and Traveller site

14 - No home of their own –living with friends as a short-term guest

15 - No home of their own –living with family as a short-term guest

16 - No home of their own –sofa surfing (sleeps on different friends’ floor or sofa each night)

17 - No home of their own –lives on the streets/rough sleeping

18 - No home of their own –squatting

19 - No home of their own –night/winter shelter

20 - No home of their own –bed and breakfast, or other hotel

21 - No home of their own –hostel

22 - No home of their own –supported accommodation

23 - No home of their own –temporary housing

24 - No home of their own –unauthorised Gypsy and Traveller encampment
|-
|Accommodation need prior to custody – ACCMNEED
|
|O
|26 - YP living with relative

27 - Independent YP –settled accommodation

28 - Independent YP –unsettled accommodation

29 - Independent YP with No Fixed Abode

31 - YP supported housing

33 - YP living in care
|-
|British Armed Forces veteran – VETERAN
|
|O
|Y - Yes
N - No

Z - Client declined to answer
|-
|Parental responsibility for children aged under 18 – PARENT
|
|O
|Y - Yes

N - No

Z - Client declined to answer
|-
|Children under 18 living with client – CHILDWTH
|
|O
|0 - No children living with client
1 - 1 child living with client

2 - 2 children living with client

n* - n children living with client

98 - Client declined to answer

99 - Undisclosed number
|-
|If client has parental responsibility and/or children living with them, what help are the children receiving? (1) – EHCSC
|
|O
|1 - Early Help (family support)
2 - Child in need (LA service)

3 - Has a child protection plan (LA service)

4 - Looked after child (LA service)

5 - None of the children are receiving any help

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|If client has parental responsibility and/or children living with them, what help are the children receiving? (2) & (3) – EHCSC2 & EHCSC3
|
|O
|1 - Early Help (family support)
2 - Child in need (LA service)

3 - Has a child protection plan (LA service)

4 - Looked after child (LA service)

6 - Other relevant child or family support service

7 - Not known

99 - Client declined to answer
|-
|Alcohol Audit Score – AUDIT
|99 = NA. Use NA only if information is not disclosed or not answered
|O
|Between 0 and 40 or 99
|-
|HIV status – HIVSTAT
|
|O
|Y - Yes
N - No

U - Unknown

Z - Declined to answer
|-
|Dual diagnosis – DUALDIAG
|
|O
|Y - Yes
N - No
|-
|Mental health interventions outside of substance misuse treatment – MHTINT
|
|O
|Y - Yes
N - No

Z - Declined to answer
|-
|Treatment for mental health during current stay – MHTXEXIT
|
|O
|Y - Yes
N - No
|-
|What was the care status of the YP in the 28 days prior to custody? – YPLCS
|
|O
|2 - Not a looked after child or child in need

1 - Looked after child

3 - Child in need
|-
|Was the YP being sexually exploited in the 28 days prior to custody? – YPSSEXEX
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Had the YP self-harmed in the 28 days prior to custody? – YPSSLFHM
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|What was the YP’s education/ employment/training status in the 28 days prior to custody? – YPSESTAT
|
|O
|1 - Mainstream education

2 - Alternative education

3 - Temporarily excluded

4 - Permanently excluded

5 - Persistent absentee

6 - Apprenticeship or training

10 - Economically inactive caring role

11 - Economically inactive health issue

12 - Voluntary work

13 - Regular employment

14 - Not in employment or education or training (NEET)

Z - Client declined to answer
|-
|Was the YP registered with GP in the 28 days prior to custody? – YPSGP
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Was the YP engaged in unsafe sex in the 28 days prior to custody? –YPSUSS
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Was the YP subject to a Child Protection Plan (CPP) in the 28 days prior to custody? – YPCPL
|
|O
|1 - Is currently subject to Child Protection Plan (CPP)

3 - Has never been subject to Child Protection Plan (CPP)

4 - Has previously been subject to a Child Protection Plan (CPP)
|-
|Has the YP been involved in gangs in the 28 days prior to custody? – YPGANGS
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Has the YP been affected by criminal exploitation in the 28 days prior to custody? – YPCRIMEX
|
|O
|N - No

Y - Yes

U - Unknown

Z - Client declined to answer
|-
|Does the young person feel they were affected by substance misuse in their close family/members of their household in the 28 days prior to custody? – YPASMFM
|
|O
|N - No
Y - Yes
|-
|Has the client used psychoactive substances during treatment episode?– NPSUSE
|
|O
|N - No

Y - Yes

Z - Client declined to answer
|-
|Has the client been provided with Reconnect support? – RECONNECT
|
|O
|1 - Yes – Standard Reconnect support
2 - Yes – Enhanced Reconnect support

3 - No
|-
|Have you ever received money or goods in exchange for sex? – SEXWORK
|
|O
|A - Yes – in the past year
B - Yes – but not in the past year

C - No

Z - Client declined to answer
|-
|Discharge Reasons – DISRSN
|
|O
|80 - Treatment completed – drug- free
81 - Treatment completed – alcohol-free

82 - Treatment completed – occasional user (not opiates or crack)

83 - Transferred – not in custody

84 - Transferred – in custody

74 - Transferred – recommissioning transfer

71 - Incomplete - onward referral offered and refused

85 - Incomplete – dropped out

86 - Incomplete – treatment withdrawn by provider

88 - Incomplete – treatment commencement declined by client

98 - Incomplete - deported

99 - Incomplete – released from court

89 - Incomplete – client died
|-
|Has the client been sentenced – SENTENCED
|
|O
|N - No
Y - Yes
|-
|Take home Naloxone and training information – THNALOX
|
|O
|N - No
Y - Yes
|-
|Is the client threatened with homelessness in the 56 days (8 weeks) following exit from secure estate? – HOMELESSEXIT
|
|O
|N - No
Y - Yes
|-
|Secure setting exit reason – EXITRSN
|
|O
|R - Released
T - Transferred

D - Died

A - Absconded
|-
|Secure setting exit destination – EXITDEST
|Permissible responses: See the NDTMS Geographic Information document for a list of DAT codes:
www.gov.uk/government/publications/geographic-information-for-the-national-drug-treatment-monitoring-system Please note, the secure setting list will change periodically as securesettings are recommissioned.
Please contact your local NDTMS team for an up to date list
|O
|
|-
|Referral on release status – RTOAGNCY
|
|O
|7 - Referred to recovery support services
8 - Referred to structured treatment provider

9 - Referred to structured treatment provider and recovery support

5 - Referred to youth offending team and structured treatment provider

6 - Referred to youth offending team

4 - No onward referral
|} 

=== Outcome Profiles ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Alchol ALCUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Consumption (alcohol) CONSMP
|999 = Not answered/not disclosed. Note NA value
999 for CDS-L and later
|O
|
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Opiates/opioids (illicit) OPIUSE
|99= NA Not answered/not disclosed
Includes street heroin and any non-prescribed
opioid, such as methadone or buprenorphine
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Crack CRAUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Cocaine COCAUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Amphetamines AMPHUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Cannabis CANNUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) Top section 1: substance use Other Problem Substance? OTDRGUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 1: substance use Tobacco use TOBUSE
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 2: substance specific risk behaviour Injected IVDRGUSE
1) Injected with a needle or syringe used by somebody else
2) Injected using a spoon, water or filter used by somebody else
|99= NA Not answered/not disclosed.
Special Note: The following header SHARING consists of 2 separate field elements, which both

contribute to what is captured under the header SHARING. Please ensure that you read the

comments below:

Y=Yes, N=No

1) If YES is given as a response in any

field, SHARING should be Y = YES

2) If NA is the response for all fields,

SHARING should be 99 = NA

3) If fields contain a combination of the

responses NA and NO, SHARING should be99= NA

4) If NO is given as a response in all fields, SHARING should be N = NO
|O
|0 to 28 days
99

Y - Yes

N - No
|-
|Treatment Outcomes Profile (TOP) TOP section 2: substance specific risk behaviour Injected IVDRGUSE
3) How often has the client had 6 or more units if female, or 8 or more if male, on a single occasion in the last 28 days/28 days prior to custody? BINGEDRINK
|Not answered/not disclosed
|O
|
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Clients rating of psychological health PSYHSTAT
|0=Poor up to 20=Good

99= NA Not answered/not disclosed
|O
|0 to 20
99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Days in paid work PWORK
|99= NA Not answered/not disclosed
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Days in volunteering or unpaid structured work placement VOLNPWORK
|99= NA Not answered/not disclosed
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Days attended college or school EDUCAT
|99= NA Not answered/not disclosed
|O
|0 to 28 days
99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Clients rating of physical health PHSTAT
|0=Poor up to 20=Good

99= NA Not answered/not disclosed
|O
|0 to 20
99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Acute housing problem ACUTHPBM
|Not answered/not disclosed.
|O
|Y - Yes

N - No

- 99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Unsuitable housing UNSTHSE
|Not answered/not disclosed.
|O
|Y - Yes

N - No

- 99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions At risk of eviction HRISK
|Not answered/not disclosed.
|O
|Y - N/A
N - N/A

- 99
|-
|Treatment Outcomes Profile (TOP) TOP section 3: health and social functioning questions Clients rating of overall quality of life QUALLIFE
|0=Poor up to 20=Good

99= NA Not answered/not disclosed
|O
|0 to 20
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Alcohol use ALCUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Consumption (alcohol) CONSMP (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 200
999
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Opiate use (illicit) OPIUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Crack use CRAUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Cocaine use COCAUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Amphetamines use AMPHUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Cannabis use CANNUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) 5.2.1 YPOR section 1: substance use Cannabis average use per day CAUSPD
|99= NA Not answered/not disclosed.
|O
|
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Tobacco/nicotine TOANIC
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Ecstasy use ECSTSYYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Solvents use SOLVYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Ketamine use KETAMNYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use GHB use GHBYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Psychoactive substances (PS) LEHIGSYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Tranquilisers (including benzodiazepines) use TRANYP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Other substance use OTDRGUSE (TOP)
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Other substance use 2 OTHR2YP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|Young People’s Outcomes Record (YPOR) YPOR section 1: substance use Other substance use 3 OTHR3YP
|99= NA Not answered/not disclosed.
|O
|0 to 28 days
99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Cannabis AFUCAN
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Alcohol AFUALC
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Tobacco/nicotine AFUTOBN
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Opiates (illicit) AFUOOL
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Crack AFUCRACK
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Cocaine AFUCOC
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Ecstasy AFUEST
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Amphetamines AFUAMP
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Solvents AFUSLV
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Ketamine AFUKET
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) GHB AFUGHB
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Psychoactive substances (PS) AFULHU
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 2: substance age of first use (to be recorded at treatment start only) Tranquilisers (including benzodiazepines) AFUTQL
|99= NA Not answered/not disclosed.
|O
|0 and 75 years

99
|-
|YPOR section 3: substance specific risk behaviour Alcohol use: in the past 28 days/28 days prior to custody has the young person drunk more than 8 units (male) or more than 6 units (female) during a single drinking episode – AAUSFWK
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|Ever injected: in your life have you ever injected a substance – LINSTUS
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|Injecting: if yes to ‘Ever injected’ LINSTUS, have you injected a substance in the past 28 days/28 days prior to custody – YPIVDRGU
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use
In the previous 28 days/28 days prior to entry into the secure estate, has the young person consumed alcohol: On a weekday during the daytime – PTEDAWDD
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On a weekday during the evening – PTEDAWDE
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On a weekend during the daytime – PTEDAWED
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On a weekend during the evening – PTEDAWEE
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On their own – PTEDOYO
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use In the previous 28 days/28 days prior to entering the secure estate, has the young person used other substances except tobacco:On a weekday during the daytime – PTEUSWDD
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On a weekday during the evening – PTEUSWDE
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|5YPOR section 4: patterns of use On a weekend during the daytime – PTEUSWED
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On a weekend during the evening – PTEUSWEE
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 4: patterns of use On their own – PTEUSOYO
|99= NA Not answered/not disclosed.
|O
|N - No

Y - Yes

- 99
|-
|YPOR section 5: health and wellbeing How satisfied the young person is with life today? LISREDYS
|0=not at all well up to 10= extremely satisfied.
99= NA Not answered/not disclosed.
|O
|0 to 10

99
|-
|YPOR section 5: health and wellbeing How anxious did the young person feel yesterday? ANSTS
|0=not at all well up to 10= extremely anxious.
99= NA Not answered/not disclosed.
|O
|0 to 10

99
|-
|YPOR section 5: health and wellbeing How happy did the young person feel yesterday? HAPSTYS
|0=not at all well up to 10= extremely happy.
99= NA Not answered/not disclosed.
|O
|0 to 10

99
|-
|YPOR section 5: health and wellbeing How well does the young person get on with family? RATEFAM
|0=not at all well up to 10= extremely well.

99= NA Not answered/not disclosed.
|O
|0 to 10

99
|-
|YPOR section 5: health and wellbeing How well does the young person get on with friends? RATEFRI
|0=not at all well up to 10= extremely well.

99= NA Not answered/not disclosed.
|O
|0 to 10

99
|-
|YPOR section 5: health and wellbeing Unsuitable housing UNSTHSE
|
|O
|N - No

Y - Yes

- 99
|} 

=== Data Linkage ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|Unique Property Reference Number (UPRN)
|UPRNs are the unique identifiers for every addressable location in Great Britain
|R
|
|}

Mental Health FHIR Store Mappings

2023-02-06T17:21:44Z

HaitemElAaouani:

The Mental Health Service Data Set (MHSDS) brings together information captured on clinical systems as part of patient care. It covers not only services provided in hospitals but also outpatient clinics and in the community, where the majority of people in contact with these services are treated.

The MHSDS is a patient level, output based, secondary uses data set which aims to deliver robust, comprehensive, nationally consistent and comparable person-based information for children, young people and adults who are in contact with services for mental health and wellbeing, Learning Disability, autism or other neurodevelopmental conditions.

You can find the expanded data specification for the MHSDS outlined below, displaying each section with its Name, Description, Conformance, and Codes with their matching values which makes up the Primary Codes & Primary Value Set. To see the full specification which includes Data Types, FHIR Targets, and the Secondary Value Sets, please go to:

To read more about the Mental Health aspect of this project, please find the full project summary at:
== Patient Demographics ==
 <ol>
 </ol>

=== Master Patient Index ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|LOCAL PATIENT IDENTIFIER (EXTENDED)
|This is a number used to identify a PATIENT uniquely within a Health Care Provider. It may be different from the PATIENT's casenote number and may be assigned automatically by the computer system. LOCAL PATIENT IDENTIFIER (EXTENDED) is used where IT systems have a LOCAL PATIENT IDENTIFIER which is longer than 10 characters and LOCAL PATIENT IDENTIFIER cannot be used for data submission.
|M
|
|-
|ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER)
|The ORGANISATION IDENTIFIER of the organisation that assigned the local patient identifier.
|M
|
|-
|ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT)
| ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) is the ORGANISATION IDENTIFIER of the Educational Establishment, including Schools.
|R
|
|-
|NHS NUMBER
|A number used to identify a PATIENT uniquely within the NHS in England and Wales
|R
|
|-
|NHS NUMBER STATUS INDICATOR CODE (MENTAL HEALTH AND MATERNITY)
|The NHS NUMBER STATUS INDICATOR of the PATIENT
|R
|01- Number present and verified

02- Number present but not traced

03- Trace required

04- Trace attempted - No match or multiple match found

05- Trace needs to be resolved - (NHS Number or patient detail conflict)

06- Trace in progress

07- Number not present and trace not required
|-
|PERSON BIRTH DATE
|The date on which a PERSON was born or is officially deemed to have been born
|R
|
|-
| POSTCODE OF USUAL ADDRESS
|The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence'
|R
|
|-
|GENDER IDENTITY CODE
|The gender identity of a PERSON as stated by the PERSON
|R
|1- Male (including trans man)

2- Female (including trans woman)

3- Non-binary

4- Other (not listed)

X- Not Known (not recorded)

Z- Not Stated (person asked but declined to provide a response)
|-
|GENDER IDENTITY SAME AT BIRTH INDICATOR
| An indication of whether the patient's gender identity is the same as their gender assigned at birth.
|R
|Y- Yes - the person's gender identity is the same as their gender assigned at birth

N- No - the person's gender identity is not the same as their gender assigned at birth

X- Not Known (not asked)

Z- Not Stated (person asked but declined to provide a response)
|-
|PERSON STATED GENDER CODE
|The gender of a PERSON. PERSON STATED GENDER CODE is self declared or inferred by observation for those unable to declare their PERSON STATED GENDER.
|R
| 1- Male

2- Female

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

X- Not Known (PERSON STATED GENDER CODE not recorded)
|-
|PERSON MARITAL STATUS
|The legal marital status of a PERSON.
| R
| S- Single

M- Married/Civil Partner

D- Divorced/Person whose Civil Partnership has been dissolved

W- Widowed/Surviving Civil Partner

P- Separated

N- Not disclosed

8- Not applicable

9- Not known
|-
|ETHNIC CATEGORY
|The ethnicity of a PERSON, as specified by the PERSON.
|R
|A- White - British

B- White - Irish

C- White - Any other White background

D- Mixed - White and Black Caribbean

E- Mixed - White and Black African

F- Mixed - White and Asian

G- Mixed - Any other mixed background

H- Asian or Asian British - Indian

J- Asian or Asian British - Pakistani

K- Asian or Asian British - Bangladeshi

L- Asian or Asian British - Any other Asian background

M- Black or Black British - Caribbean

N- Black or Black British - African

P- Black or Black British - Any other Black background

R- Other Ethnic Groups - Chinese

S- Other Ethnic Groups - Any other ethnic group

Z- Not stated

99- Not known
|-
|ETHNIC CATEGORY 2021
|Placeholder data item to accommodate the 2021 census when it goes live
|P
|
|-
|LANGUAGE CODE (PREFERRED)
|LANGUAGE CODE (PREFERRED) is the language the PATIENT prefers to use for communication with a Health Care Provider. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions.
|R
| All Spoken Languages

ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki>

Extensions

q1- Braille (for people who are unable to see)

q2- American Sign Language

q3- Australian Sign Language

q4- British Sign Language

q5- Makaton (devised for children and adults with a variety of communication and Learning Disabilities)
|-
|PERSON DEATH DATE
|The date on which a person died or is officially deemed to have died, as recorded on the death certificate.
|R
|
|} 

=== GP Practice Registration ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
| GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
|The ORGANISATION CODE of the GP Practice that the PATIENT is registered with.
|M
|
|-
|START DATE (GMP PATIENT REGISTRATION)
|Start Date on which the PERSON registered with a General Medical Practitioner Practice.
|R
|
|-
|END DATE (GMP PATIENT REGISTRATION)
|The DATE on which the PERSON ceased to be registered with a General Medical Practitioner Practice.
|R
|
|} 

=== Accommodation Status ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|ACCOMMODATION TYPE
|An indication of the type of accommodation that a PATIENT currently has. This should be based on the PATIENT's main or permanent residence.
|M
|01- Owner occupier

02- Tenant - Local Authority/Arms Length Management Organisation/registered social housing provider

03- Tenant - private landlord

04- Living with family

05- Living with friends

06- University or College accommodation

07- Accommodation tied to job (including Armed Forces)

08- Mobile accommodation

09- Care home without nursing

10- Care home with nursing

11- Specialist Housing (with suitable adaptations to meet impairment needs and support to live independently)

12- Rough sleeper

13- Squatting

14- Sofa surfing (sleeps on different friends floor each night)

15- Staying with friends/family as a short term guest

16- Bed and breakfast accommodation to prevent or relieve homelessness

17- Sleeping in a night shelter

18- Hostel to prevent or relieve homelessness

19- Temporary housing to prevent or relieve homelessness

20- Admitted patient settings

21- Criminal justice settings

98- Other (not listed)
|-
|SETTLED ACCOMMODATION INDICATOR
|An indication of whether the main/permanent residence of the patient is settled accommodation.
|R
|Y- Yes - Settled Accommodation

N- No - Non-settled Accommodation

Z- Not Stated (PATIENT asked but declined to provide a response)

9- Not known (Not Recorded)
|-
|ACCOMMODATION TYPE RECORDED DATE
|The PERSON PROPERTY RECORDED DATE when the ACCOMMODATION TYPE was recorded.
|R
|
|-
|SECURE CHILDRENS HOME PLACEMENT TYPE
|The type of placement for a child or young person accommodated in a Secure Children's Home.
|R
|1- Secure welfare placement

2- Youth justice placement
|-
|ACCOMMODATION TYPE START DATE
|The date that the patient's accommodation type started.
|R
|
|-
|ACCOMMODATION TYPE END DATE
|The date that the patient's accommodation type ended.
|R
|
|} 

=== Employment Status ===
{| class="wikitable"
!Name
!Description
! Conformance
!Codes & Primary Value Set
|-
| EMPLOYMENT STATUS
| The current PRIMARY EMPLOYMENT status of a PERSON.
|M
|01- Employed

02- Unemployed and actively seeking work

03- Undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training as a student and not working or actively seeking work

04- Long-term sick or disabled, those receiving government sickness and disability benefits

05- Looking after the family or home as a homemaker and not working or actively seeking work

06- Not receiving government sickness and disability benefits and not working or actively seeking work

07- Unpaid voluntary work and not working or actively seeking work

08- Retired

ZZ- Not Stated (PERSON asked but declined to provide a response)
|-
|EMPLOYMENT STATUS START DATE
|The date that the patient's employment status started.
|R
|
|-
|EMPLOYMENT STATUS END DATE
|The date that the patient's employment status ended.
|R
|
|-
|EMPLOYMENT STATUS RECORDED DATE
| The date that the patient's employment status details were recorded by the healthcare professional.
|R
|
|-
|WEEKLY HOURS WORKED
|The number of hours worked in a typical week.
|R
|01- 30+ hours

02- 16-29 hours

03- 5-15 hours

04- 1-4 hours

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

98- Not applicable (PERSON not employed)

99- Number of hours worked not known
|} 

=== Patient Indicators ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
|An indication of whether a disabled PATIENT needs constant (round the clock) care and/or supervision for maintenance of their safety and/or wellbeing.
|R
|Y - Yes: PATIENT requires constant care and/or supervision

N - No: PATIENT does not require constant care and/or supervision
|-
| PARENTAL RESPONSIBILITIES INDICATOR
|An indication of whether a PATIENT has Parental Responsibilities for a child or young person, as stated by the PATIENT.
|R
|Y - Yes: PATIENT has parental responsibilities for a child or young person

N - No: PATIENT does not have parental responsibilities for a child or young person

Z - Not Stated (PATIENT asked but declined to provide a response)

X - Not Known (not recorded)
|-
|YOUNG CARER INDICATOR
| An indication of whether a child or young person (PATIENT) has a caring role for an ill or disabled Parent/Carer/Sibling.
|R
|Y - Yes: PATIENT has a caring role for an ill or disabled parent, Carer or sibling

N - No: PATIENT does not have a caring role for an ill or disabled parent, Carer or sibling

Z.- Not Stated: (PATIENT asked but declined to provide a response)

X.- Not known whether the PATIENT is a young Carer
|-
|LOOKED AFTER CHILD INDICATOR
|An indication of whether a PATIENT is a Looked After Child.
|R
|Yes - is a Looked After Child

No - is not a Looked After Child

Not Known if the PATIENT is a Looked After Child
|-
|LOOKED AFTER CHILD LEGAL STATUS
|The legal status of the Looked After Child. This refers to the Children's Act 1989: see details <nowiki>https://www.legislation.gov.uk/ukpga/1989/41/contents</nowiki>
|R
|01 - Section 20 Voluntary Agreement

02 = Section 31 Care Order

03 = Section 38 Interim Care Order

08 = Other (not listed)
|-
|EDUCATIONAL ASSESSMENT OUTCOME
| The outcome of an EDUCATIONAL ASSESSMENT.
|R
|01 - No Special Education Needs

05 - Subject to Education, Health and Care Plan (EHC)
|-
|CHILD PROTECTION PLAN INDICATION CODE
|An indication of whether the child or young person (PATIENT) is/has previously been subject to a child protection plan.
|R
|1 - Has never been subject to a Child Protection Plan

2 - Has previously been subject to a Child Protection Plan

3 - Is currently subject to a Child Protection Plan

X - Not Known whether the PATIENT is or has ever been the subject of a Child Protection Plan
|-
|EX-BRITISH ARMED FORCES INDICATOR
|An indication of whether the PATIENT is an ex-member of the British Armed Forces, i.e. army, navy or air force, or is a dependant of a person who is an ex-services member.
|R
|02 - Ex-services member

03 - Not an ex-services member or their dependant

05 - Dependant of an ex-services member

UU - Unknown (PATIENT asked and does not know or is not sure)

ZZ - Not stated (PATIENT asked but declined to provide a response)
|-
|OFFENCE HISTORY INDICATION CODE
|An indication of whether the PATIENT has a history of offences, including index offences (i.e. is recordable, committed in England and Wales, prosecuted by the police and is not a breach of the peace).

This is completed by CARE PROFESSIONALS based on the PATIENT history, informed by referral information.
|R
|1 - No - No offence

2 - Yes - Less serious offence

3 - Yes - Serious offence

X - Not Known (Not Recorded)
|-
|PRODROME PSYCHOSIS DATE
|Date at which first noticeable change in behaviour or mental state occurred prior to emergence of full-blown psychosis for the patient. There should be a clear deterioration in functioning from previous levels.

Examples include poor attendance/worsening performance at school/work, trouble sleeping, withdrawing from/fighting with friends/family, attenuated psychotic symptoms (increased suspiciousness,/jealously, occasionally hearing name being called when no' ones around, whisperings, slight confusion in thinking etc.).
|R
|
|-
|EMERGENT PSYCHOSIS DATE
|Date at which there was first clear evidence of a positive psychotic symptom for the patient (i.e. delusion, hallucination, or thought disorder), regardless of its duration.

Such a symptom would be scored 4 or more on the PANSS.
|R
|
|-
|MANIFEST PSYCHOSIS DATE
| Date at which a positive psychotic symptom has lasted for a week for the patient. This is usually just 7 days after the date of the first psychotic symptom.
|R
|
|-
|FIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION)
| Date the patient was first prescribed anti-psychotic medication following referral into an Early Intervention in Psychosis (EIP) Service.
|R
|
|-
| PSYCHOSIS FIRST TREATMENT START DATE
|Date the patient first commenced prescribed (not PRN) anti-psychotic medication, following referral into an Early Intervention in Psychosis (EIP) Service, and thereafter was compliant for at least 75% of the time during the subsequent month (using clinical judgement).

Note: For the majority of people this will be the same date as the date of prescription.
|R
|
|-
|REASONABLE ADJUSTMENT REQUIRED INDICATOR
|An indicator to alert the clinician that this patient may need a reasonable adjustment made
|R
|Y - Yes - the patient requires a Reasonable Adjustment

N - No - the patient does not require a Reasonable Adjustment
|} 

=== Mental Health Care Coordinator ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
|The start date of a Mental Health Care Coordinator Assignment Period for a patient.
|M
|
|-
|CARE PROFESSIONAL LOCAL IDENTIFIER
|A unique local CARE PROFESSIONAL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
 
|R
|
|-
|END DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
|The end date of a Mental Health Care Coordinator Assignment Period for a patient.
|R
|
|-
| CARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH)
|The type of service or team the Care Professional is associated with.
|R
|A01 Day Care Service

A02 Crisis Resolution Team/Home Treatment Service

A05 Primary Care Mental Health Service

A06 Community Mental Health Team - Functional

A07 Community Mental Health Team - Organic

A08 Assertive Outreach Team

A09 Community Rehabilitation Service

A10 General Psychiatry Service

A11 Psychiatric Liaison Service

A12 Psychotherapy Service

A13 Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis

A15 Young Onset Dementia Team

A16 Personality Disorder Service

A17 Memory Services/Clinic/Drop in service

A18 Single Point of Access Service

A19 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service

A21 Crisis Café/Safe Haven/Sanctuary Service

A22 Walk-in Crisis Assessment Unit Service

A23 Psychiatric Decision Unit Service

A24 Acute Day Service

A25 Crisis House Service

B01 Forensic Mental Health Service

B02 Forensic Learning Disability Service

C01 Autism Service

C02 Specialist Perinatal Mental Health Community Service

C04 Neurodevelopment Team

C05 Paediatric Liaison Service

C06 Looked After Children Service

C07 Youth Offending Service

C08 Acquired Brain Injury Service

C10 Community Eating Disorder Service

D01 Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service

D04 Asylum Service

D05 Individual Placement and Support Service

D06 Mental Health In Education Service

D07 Problem Gambling Service

D08 Rough Sleeping Service

E01 Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service

E03 Specialist Parenting Service

E04 Enhanced/Intensive Support Service

F01 Mental Health Support Team

F02 Maternal Mental Health Service

F03 Mental Health Services for Deaf people

F04 Veterans Complex Treatment Service

F05 Enhanced care in care homes teams

F06 Mental Health and Wellbeing Hubs

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

Z02 Other Mental Health Service - out of scope of National Tariff Payment System
|} 

=== DisabilityType ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
| DISABILITY CODE
| The DISABILITY of a PERSON.

This could be where:

the PERSON has been diagnosed as disabled or

the PERSON considers themself to be disabled.
|M
|01 Behaviour and Emotional

02 Hearing

03 Manual Dexterity

04 Memory or ability to concentrate, learn or understand (Learning Disability)

05 Mobility and Gross Motor

06 Perception of Physical Danger

07 Personal, Self Care and Continence

08 Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)

09 Sight

10 Speech

XX Other (not listed)

NN No Disability

ZZ Not Stated (Person asked but declined to provide a response)
|-
| DISABILITY IMPACT PERCEPTION
|The patient's perception of whether their day-to-day activities are limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months.
|R
|01 - Yes – limited a lot

02 - Yes – limited a little

03 - No - not limited

04 - Prefer not to say (Patient asked but declined to provide a response)
|} 

=== Care Plan Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
| CARE PLAN IDENTIFIER
| A unique identifierfor Care Plan.
|M
|
|-
|CARE PLAN TYPE (MENTAL HEALTH)
|The type of Care Plan for the patient, recorded by the service.
|M
|10 - Mental Health Care Plan

11 - Urgent and Emergency Mental Health Care Plan

12 - Mental Health Crisis Plan

13 - Positive Behaviour Support Plan

14 - Child or Young Person's Mental Health Transition Plan
|-
|CARE PLAN CREATION DATE
|The date that a Care Plan was created for a patient.
|M
|
|-
|CARE PLAN CREATION TIME
|The time that a Care Plan was created for a patient.
|R
|
|-
|CARE PLAN LAST UPDATED DATE
|The date that the Care Plan was last updated for a patient.

Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Date.
|R
|
|-
|CARE PLAN LAST UPDATED TIME
|The time that the Care Plan was last updated for a patient.

Where the Care Plan has not otherwise been updated this will be the same as the Care Plan Creation Time.
|R
|
|-
| CARE PLAN IMPLEMENTATION DATE
|The date that the Care Plan was implemented for a patient.
|R
|
|} 

=== Care Plan Agreement ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|FAMILY INVOLVED IN CARE PLAN INDICATOR
|An indication of whether a member of the patient's family is currently involved in the patient's care plan.

This only needs to be captured for inpatients that are in scope of Transforming Care.
|R
|Y - Yes - a member of the patient's family is currently involved in the patient's care plan

N - No - a member of the patient's family is not currently involved in the patient's care plan

9 - Not known if the PATIENT's family is currently involved in the PATIENT's CARE PLAN
|-
|FAMILY NOT INVOLVED IN CARE PLAN REASON
|The reason that the patient's family is not currently involved in the patient's care plan.

This only needs to be captured for inpatients that are in scope of Transforming Care.
|R
|01 - At the request of the patient

02 - Access restrictions on the family

03 - No known family

08 - Other (not listed)
|-
|CARE PLAN CONTENT AGREED BY
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the CARE PLAN for the PATIENT.
|M
|Patient or Patient Proxy

Advocate

Clinical Service or Team

Local Community Support Team

Commissioner

Family member or carer with parental responsibility

Family member or carer without parental responsibility
|-
|CARE PLAN CONTENT AGREED DATE
|The date on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy.
|R
|10 - Patient or Patient Proxy

12 - Advocate

13 - Clinical Service or Team

14 - Local Community Support Team

15 - Commissioner

16 - Family member or carer with parental responsibility

17 - Family member or carer without parental responsibility
|-
|CARE PLAN CONTENT AGREED TIME
| The time on which the content of the CARE PLAN was agreed by a PATIENT or Patient Proxy
|R
|
|} 

=== Assistive Technology to Support Disability Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
|The SNOMED CT concept ID which is used to identify the finding relating to the assistive technology that a PATIENT is dependent on.
|M
|
|-
|PRESCRIPTION TIMESTAMP (ASSISTIVE TECHNOLOGY)
|The date, time and time zone for the prescription of Assistive Technology.
|R
|
|} 

=== Social and Personal Circumstances ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
|The SNOMED CT concept ID which is used to identify a Social and Personal Circumstance for a person.
|M
|
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED TIMESTAMP
|The date, time and time zone on which the Social and Personal Circumstance was recorded.
|R
|
|} 

=== Overseas Visitor Charging Category ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|OVERSEAS VISITOR CHARGING CATEGORY
|The charging category relating to an OVERSEAS VISITOR STATUS.
|M
|A - Standard NHS-funded PATIENT

B - Immigration Health Surcharge payee

C - Charge-exempt Overseas Visitor (European Economic Area)

D - Chargeable European Economic Area PATIENT

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

F - Chargeable non-European Economic Area PATIENT

P - Decision Pending on OVERSEAS VISITOR CHARGING CATEGORY

9 - OVERSEAS VISITOR CHARGING CATEGORY Not Known (Not Recorded)
|-
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE FROM DATE
|The date when the PATIENT's OVERSEAS VISITOR CHARGING CATEGORY was applicable from. If the applicable date is not available, this should be the date the OVERSEAS VISITOR CHARGING CATEGORY was recorded.
|R
|
|-
|OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE END DATE
|The date the OVERSEAS VISITOR CHARGING CATEGORY was applicable until.
|R
|
|} 

=== Mental Health Currency Model ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|MENTAL HEALTH RESOURCE GROUP TYPE (SNOMED CT)
|The SNOMED CT EXPRESSION which is used to identify the Mental Health Resource Group type.
|P
|
|-
|START DATE (MENTAL HEALTH RESOURCE GROUP)
|When a PATIENT is assessed in a Mental Health Service and assigned a Mental Health Resource Group
|P
|
|-
|END DATE (MENTAL HEALTH RESOURCE GROUP)
|When a PATIENT either changes their Mental Health Resource Group or leaves the Mental Health Service.
|P
|
|} 

=== Service or Team Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SERVICE REQUEST IDENTIFIER
|The unique identifier for a SERVICE REQUEST. It would normally be automatically generated by the local system upon recording a new Referral, although could be manually assigned.
|M
|
|-
|ORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION commissioning health care.
|M
|
|-
|REFERRAL REQUEST RECEIVED DATE
|This is the date the REFERRAL REQUEST was received by the Health Care Provider.
|M
|
|-
|REFERRAL REQUEST RECEIVED TIME
|This records the time the REFERRAL REQUEST was received. This item is only required for 'urgent' priority referrals into services with target waiting times measured in hours e.g. rapid response teams or urgent care.
|R
|
|-
|NHS SERVICE AGREEMENT LINE NUMBER
|A number (alphanumeric) to provide a unique identifier for a line within a NHS SERVICE AGREEMENT. An NHS SERVICE AGREEMENT is a formal agreement between a commissioner Organisation and one or more Health Care Provider Organisations for the provision of PATIENT care SERVICES.
|R
|
|-
|SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
|The category of the specialised Mental Health Service provided in a SERVICE PROVIDED UNDER AGREEMENT. The SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE National Codes are published by NHS England and can be accessed at Specialised Services Reporting Requirements.
|R
|
|-
|SOURCE OF REFERRAL FOR MENTAL HEALTH SERVICES DATA SET
|The source of referral to a Mental Health Service.
|R
|A1 - Primary Health Care: General Medical Practitioner Practice

A2 - Primary Health Care: Health Visitor

A3 - Other Primary Health Care

A4 - Primary Health Care: Maternity Service

B1 - Self-Referral: Self

B2 - Self-Referral: Carer/Relative

C1 - Local Authority and Other Public Services: Social Services

C2 - Local Authority and Other Public Services: Education Service / Educational Establishment

C3 - Local Authority and Other Public Services: Housing Service

D1 - Employer

D2 - Employer: Occupational Health

E1 - Justice System: Police

E2 - Justice System: Courts

E3 - Justice System: Probation Service

E4 - Justice System: Prison

E5 - Justice System: Court Liaison and Diversion Service

E6 - Justice System: Youth Offending Team

F1 - Child Health: School Nurse

F2 - Child Health: Hospital-based Paediatrics

F3 - Child Health: Community-based Paediatrics

G1 - Independent sector - Medium Secure Inpatients

G2 - Independent Sector - Low Secure Inpatients

G3 - Other Independent Sector Mental Health Services

G4 - Voluntary Sector

H1 - Acute Secondary Care: Emergency Care Department

H2 - Other secondary care specialty

I1 - Temporary transfer from another Mental Health NHS Trust

I2 - Permanent transfer from another Mental Health NHS Trust

M1 - Other: Asylum Services

M2 - Other: Telephone or Electronic Access Service

M3 - Other: Out of Area Agency

M4 - Other: Drug Action Team / Drug Misuse Agency

M5 - Other: Jobcentre Plus

M6 - Other SERVICE or agency

M7 - Other: Single Point of Access Service

M9 - Other: Urgent and Emergency Care Ambulance Service

N3 - Improving Access to Psychological Therapies Service

P1 - Internal Referral

Q1 - Mental Health Drop In Service
|-
|ORGANISATION IDENTIFIER (REFERRING)
|The ORGANISATION IDENTIFIER of the Organisation from which the referral is made, such as a GP Practice, NHS Trust or NHS Foundation Trust.
|R
|
|-
|REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|The will indicate the STAFF GROUP of the Care Professional referring the patient into the mental health service. This data item is not required where the referrer is not a care professional e.g. self-referral, carer or employer.
|R
|A01 Art Therapist

A02 Clinical Psychologist

A03 Dietitian

A04 Dramatherapist

A05 Music Therapist

A06 Occupational Therapist

A07 Orthotist

A08 Physiotherapist

A09 Podiatrist

A10 Prosthetist

A11 Psychotherapist

A12 Radiographer

A13 Speech and Language Therapist

A14 Orthoptist

M01 Community Dentist

M02 Consultant

M03 General Medical Practitioner

M04 General Practitioner with an Extended Role (GPwER)

N01 Midwife

N02 District Nurse

N03 Health Visitor

N04 Macmillan Nurse

N05 School Nurse

N06 Specialist Nursing - Active Case Management (Community Matrons)

N07 Specialist Nursing - Arthritis Nursing/Liaison

N08 Specialist Nursing - Asthma and Respiratory Nursing/Liaison

N09 Specialist Nursing - Breast Care Nursing/Liaison

N10 Specialist Nursing - Cancer Related

N11 Specialist Nursing - Cardiac Nursing/Liaison

N12 Specialist Nursing - Children's Services

N13 Specialist Nursing - Community Cystic Fibrosis

N14 Specialist Nursing - Continence Services

N15 Specialist Nursing - Diabetic Nursing/Liaison

N16 Specialist Nursing - Enteral Feeding Nursing Services

N17 Specialist Nursing - Haemophilia Nursing Services

N19 Specialist Nursing - Infectious Diseases

N20 Specialist Nursing - Intensive Care Nursing

N21 Specialist Nursing - Palliative/Respite Care

N22 Specialist Nursing - Parkinson's and Alzheimers Nursing/Liaison

N23 Specialist Nursing - Rehabilitation Nursing

N24 Specialist Nursing - Stoma Care Services

N25 Specialist Nursing - Tissue Viability Nursing/Liaison

N26 Specialist Nursing - Transplantation Patients Nursing Services

N27 Specialist Nursing - Treatment Room Nursing Services

N28 Specialist Nursing - Tuberculosis Specialist Nursing

N29 Specialist Nursing - Other Specialist Nursing

N30 Specialist Nursing - Safeguarding

N31 Practice Nursing

N32 Staff Nurse

N33 Other Registered Nurse

N34 Public Health Nurse

C01 Appliances Technician

C02 Audiologist

C03 Counsellor

C04 Nursery Nurse

C06 Play Therapist

C07 Social Worker

C08 Voluntary Care Worker

C09 Screener (in a National Screening Programme)

C99 Other Care Professional (not listed)
|-
|CLINICAL RESPONSE PRIORITY TYPE
|The clinical response priority of a SERVICE REQUEST.
|R
|1 - Emergency

2 - Urgent/Serious

3 - Routine

4 - Very Urgent
|-
|PRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
|This is the primary presenting condition or symptom for which the patient was referred to a Mental Health Service
|R
|01 - (Suspected) First Episode Psychosis

02 - Ongoing or Recurrent Psychosis

03 - Bi polar disorder

04 - Depression

05 - Anxiety

06 - Obsessive compulsive disorder

07 - Phobias

08 - Organic brain disorder

09 - Drug and alcohol difficulties

10 - Unexplained physical symptoms

11 - Post-traumatic stress disorder

12 - Eating disorders

13 - Perinatal mental health issues

14 - Personality disorders

15 - Self harm behaviours

16 - Conduct disorders

18 - In crisis

19 - Relationship difficulties

20 - Gender Discomfort issues

21 - Attachment difficulties

22 - Self - care issues

23 - Adjustment to health issues

24 - Neurodevelopmental Conditions, excluding Autism

25 - Suspected Autism

26 - Diagnosed Autism

27 - Preconception perinatal mental health concern

28 - Gambling disorder

29 - Community Perinatal Mental Health Partner Assessment

30 - Behaviours that challenge due to a Learning Disability
|-
|REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH)
|The reason why a SERVICE has received a REFERRAL REQUEST, for a PATIENT: -with assessed acute mental health needs requiring adult mental health acute inpatient care and -who is resident outside of the ORGANISATION's usual local network of SERVICES.
|R
|10 - Unavailability of bed at referring organisation

11 - Safeguarding

12 - Offending restrictions

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

14 - Patient choice

15 - Patient away from home

99 - Not Known (Not Recorded)
|-
|DECISION TO TREAT DATE (MENTAL HEALTH HOME TREATMENT)
|The date that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|R
|
|-
|DECISION TO TREAT TIME (MENTAL HEALTH HOME TREATMENT)
|The time that it was first identified that the patient needs mental health treatment, but the formal service request has not yet been created. However, the patient may be formally under the care of the Home Treatment Service. This applies to home treatments: <nowiki>https://www.cwp.nhs.uk/services-and-locations/services/home-treatment/#:~:text=Home%20Treatment%20(HT)%20teams%20are,to%20admission%20as%20an%20inpatient</nowiki>
|R
|
|-
|DISCHARGE PLAN CREATION DATE
|The date that a Discharge Plan was created for a patient.
|R
|
|-
|DISCHARGE PLAN CREATION TIME
|The time that a Discharge Plan was created for a patient.
|R
|
|-
|DISCHARGE PLAN LAST UPDATED DATE
|The date that the Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Date.
|R
|
|-
|DISCHARGE PLAN LAST UPDATED TIME
|The time that a Discharge Plan was last updated for a patient. Where the Discharge Plan has not otherwise been updated this will be the same as the Discharge Plan Creation Time.
|R
|
|-
|SERVICE DISCHARGE DATE
|Service Discharge Date is the date a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
|R
|
|-
|SERVICE DISCHARGE TIME
|Service Discharge Time is the time a PATIENT was discharged from a SERVICE. This would occur once all the services or teams (for example as part of a multidisciplinary team) have finished treating a patient under a specific referral.
|R
|
|} 

=== Other Reason for Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|OTHER REASON FOR REFERRAL (MENTAL HEALTH)
|The secondary presenting conditions or symptoms for which the patient was referred to a Mental Health Service.
|M
|1 - (Suspected) First Episode Psychosis

2 - Ongoing or Recurrent Psychosis

3 - Bi polar disorder

4 - Depression

5 - Anxiety

6 - Obsessive compulsive disorder

7 - Phobias

8 - Organic brain disorder

9 - Drug and alcohol difficulties

10 - Unexplained physical symptoms

11 - Post-traumatic stress disorder

12 - Eating disorders

13 - Perinatal mental health issues

14 - Personality disorders

15 - Self harm behaviours

16 - Conduct disorders

18 - In crisis

19 - Relationship difficulties

20 - Gender Discomfort issues

21 - Attachment difficulties

22 - Self - care issues

23 - Adjustment to health issues

24 - Neurodevelopmental Conditions, excluding Autism

25 - Suspected Autism

26 - Diagnosed Autism

27 - Preconception perinatal mental health concern

28 - Gambling disorder

29 - Community Perinatal Mental Health Partner Assessment

30 - Behaviours that challenge due to a Learning Disability
|} 

=== Service or Team Type Referred To ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|R
|
|-
|SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
|The type of service or team within a Mental Health Service that a patient was referred to
|M
|A01 Day Care Service
A02 Crisis Resolution Team/Home Treatment Service

A05 Primary Care Mental Health Service

A06 Community Mental Health Team - Functional

A07 Community Mental Health Team - Organic

A08 Assertive Outreach Team

A09 Community Rehabilitation Service

A10 General Psychiatry Service

A11 Psychiatric Liaison Service

A12 Psychotherapy Service

A13 Psychological Therapy Service (non IAPT)

A14 Early Intervention Team for Psychosis

A15 Young Onset Dementia Team

A16 Personality Disorder Service

A17 Memory Services/Clinic/Drop in service

A18 Single Point of Access Service

A19 24/7 Crisis Response Line

A20 Health Based Place Of Safety Service

A21 Crisis Café/Safe Haven/Sanctuary Service

A22 Walk-in Crisis Assessment Unit Service

A23 Psychiatric Decision Unit Service

A24 Acute Day Service

A25 Crisis House Service

B01 Forensic Mental Health Service

B02 Forensic Learning Disability Service

C01 Autism Service

C02 Specialist Perinatal Mental Health Community Service

C04 Neurodevelopment Team

C05 Paediatric Liaison Service

C06 Looked After Children Service

C07 Youth Offending Service

C08 Acquired Brain Injury Service

C10 Community Eating Disorder Service

D01 Substance Misuse Team

D02 Criminal Justice Liaison and Diversion Service

D03 Prison Psychiatric Inreach Service

D04 Asylum Service

D05 Individual Placement and Support Service

D06 Mental Health In Education Service

D07 Problem Gambling Service

D08 Rough Sleeping Service

E01 Community Team for Learning Disabilities

E02 Epilepsy/Neurological Service

E03 Specialist Parenting Service

E04 Enhanced/Intensive Support Service

F01 Mental Health Support Team

F02 Maternal Mental Health Service

F03 Mental Health Services for Deaf people

F04 Veterans Complex Treatment Service

F05 Enhanced care in care homes teams

F06 Mental Health and Wellbeing Hubs

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

Z02 Other Mental Health Service - out of scope of National Tariff Payment System
|-
|REFERRAL CLOSURE DATE
|The date the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL CLOSURE TIME
|The time the Referral Request to a Health Care Provider's Service was closed by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL REJECTION DATE
|The date the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL REJECTION TIME
|The time the Referral Request to a Health Care Provider's Service was rejected by the Health Care Provider's Service. The overarching referral may remain open if another service or team involved in the same referral is still actively treating the patient.
|R
|
|-
|REFERRAL CLOSURE REASON
|The reason that a Referral Request has been closed. A Referral Request can be closed as a result of a Patient being discharged from the SERVICE. Cancelled referrals such as those entered onto a system in error should not be submitted within the data set.
|R
|01 - Admitted elsewhere (at the same or other Health Care Provider)

02 - Treatment completed

03 - Moved out of the area

04 - No further treatment appropriate

05 - Patient did not attend

06 - Patient died

07 - Patient requested discharge

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

09 - PATIENT refused to be seen
|-
|REFERRAL REJECTION REASON
|The reason that a Referral Request has been rejected by the SERVICE.
|R
|01 - Duplicate REFERRAL REQUEST (PATIENT already undergoing treatment for the same condition at the same or other Health Care Provider)

02 - Inappropriate referral request (Referral request is inappropriate for the services offered by the Health Care Provider)

03 - Incomplete REFERRAL REQUEST (incomplete information on REFERRAL REQUEST)
|} 

=== Referral to Treatment (RTT) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PATIENT PATHWAY IDENTIFIER
|An identifier, which together with the ORGANISATION CODE of the issuer, uniquely identifies a PATIENT PATHWAY.
|R
|
|-
|ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION issuing the PATIENT PATHWAY IDENTIFIER.
|R
|
|-
|WAITING TIME MEASUREMENT TYPE (MENTAL HEALTH)
|The type of waiting time measurement methodology which may be applied during a PATIENT PATHWAY. The methodology applied may be for one part of a PATIENT PATHWAY, such as the measurement of a REFERRAL TO TREATMENT PERIOD, or other parts of the PATIENT PATHWAY according to Department of Health policy.
|M
|02 - Allied Health Professional Referral To Treatment Measurement

09 - Other Referral To Treatment Measurement Type (not listed)
|-
|REFERRAL TO TREATMENT PERIOD START DATE
|The start date of a REFERRAL TO TREATMENT PERIOD.
|R
|
|-
|REFERRAL TO TREATMENT PERIOD END DATE
|The end date of a REFERRAL TO TREATMENT PERIOD.
|R
|
|-
|REFERRAL TO TREATMENT PERIOD STATUS
|The status of an ACTIVITY (or anticipated ACTIVITY) for the REFERRAL TO TREATMENT PERIOD decided by the lead CARE PROFESSIONAL.
|R
|10 - First activity in a Referral to Treatment Period

11 - First activity at the start of a new Referral to Treatment Period following Active Monitoring

12 - First activity at the start of a new Referral to Treatment Period following a decision to refer directly to the consultant or NHS Allied Health Professional Service (Referral To Treatment Measurement) for a separate condition

20 - Subsequent activity during a Referral to Treatment Period - further activities anticipated

21 - Subsequent activity by another Health Care Provider following a transfer to another Health Care Provider during a Referral to Treatment Period anticipated

30 - End of the Referral to Treatment Period: Start of First Definitive Treatment

31 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the patient

32 - End of the Referral to Treatment Period: Start of Active Monitoring initiated by the care professional

33 - End of the Referral to Treatment Period: Did not attend - the patient did not attend the first Care activity after the referral

34 - End of the Referral to Treatment Period: Decision not to treat - decision not to treat made or no further contact required

35 - End of the Referral to Treatment Period: patient declined offered treatment

36 - End of the Referral to Treatment Period: patient died before treatment

90 - Not part of a Referral to Treatment Period: After treatment - First Definitive Treatment occurred previously (e.g. admitted as an emergency from A&E or the activity is after the start of treatment)

91 - Not part of a Referral to Treatment Period: Care activity during Active Monitoring

92 - Not part of a Referral to Treatment Period: Not yet referred for treatment, undergoing diagnostic tests by General Practitioner before referral

98 - Not part of a Referral to Treatment Period: activity not applicable to Referral to Treatment Periods

99 - Referral to Treatment Period status not yet known
|} 

=== Onward Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DECISION TO REFER DATE (ONWARD REFERRAL)
|DECISION TO REFER DATE (ONWARD REFERRAL) is the DATE on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
|R
|
|-
|DECISION TO REFER TIME (ONWARD REFERRAL)
|DECISION TO REFER TIME (ONWARD REFERRAL) is the TIME on which a decision was made to refer the PATIENT from one SERVICE to another SERVICE, which may be in the same or a different ORGANISATION.
|R
|
|-
|ONWARD REFERRAL DATE
|The date the patient was referred to another service, which may be in the same or a different organisation.
|M
|
|-
|ONWARD REFERRAL TIME
|The time the patient was referred to another service, which may be in the same or a different organisation.
|R
|
|-
|ONWARD REFERRAL REASON (MENTAL HEALTH SERVICES DATA SET)
|The reason why the PATIENT was referred to another service, which may be in the same or a different organisation.
|R
|01 - Transfer of Clinical Responsibility
02 - For Opinion Only

03 - For Diagnostic Test Only

04 - New Referral (Non Transfer)

96 - Other (not listed)

98 - Onward Referral Reason Not Applicable

99 - Not Known (Not Recorded)
|-
|REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH)
|The reason that a patient with assessed acute mental health needs requiring adult mental health acute inpatient care is being referred to a unit that does not form part of the organisation's usual local network of services, where the patient's Mental Health Care Coordinator cannot visit the patient as often as stated in the Organisation's policy.
|R
|10 - Unavailability of bed at referring organisation

11 - Safeguarding

12 - Offending restrictions

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

14 - Patient choice

99 - Not Known (Not Recorded)
|-
|ORGANISATION IDENTIFIER (RECEIVING)
|ORGANISATION IDENTIFIER (RECEIVING) is the ORGANISATION IDENTIFIER of the ORGANISATION that is receiving the PATIENT from another Health Care Provider.
|R
|
|-
|CODED REFERRAL PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows a specific purpose for the onward referral to be attributed.
|R
|
|} 

=== Discharge Plan Agreement ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DISCHARGE PLAN CONTENT AGREED BY
|The type of PERSON, SERVICE or ORGANISATION that agreed the content of the Discharge Plan for the PATIENT.
|M
|10 - Patient or Patient Proxy

12 - Advocate

13 - Clinical Service or Team

14 - Local Community Support Team

15 - Current Commissioner

16 - Commissioner of Planned Discharge Destination

17 - Family member or carer with parental responsibility

18 - Family member or carer without parental responsibility
|-
|DISCHARGE PLAN CONTENT AGREED DATE
|The date on which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|R
|
|-
|DISCHARGE PLAN CONTENT AGREED TIME
|RThe time at which the content of the Discharge Plan was agreed by a PATIENT or Patient Proxy.
|R
|
|} 

=== Medication Prescription ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PRESCRIPTION IDENTIFIER
|The unique identifier of a PRESCRIPTION.
|P
|
|-
|PRESCRIPTION DATE (MEDICATION)
|The date on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|P
|
|-
|PRESCRIPTION TIME (MEDICATION)
|The time on which the PRESCRIPTION of Medication was signed by the CARE PROFESSIONAL.
|P
|
|} 

=== Care Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE CONTACT IDENTIFIER
|The CARE CONTACT IDENTIFIER is used to uniquely identify the CARE CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Care Contact, although could be manually assigned.
|M
|
|-
|CARE PROFESSIONAL TEAM LOCAL IDENTIFIER
|A unique local CARE PROFESSIONAL TEAM IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|R
|
|-
|CARE CONTACT DATE
|The date on which a Care Contact took place, or, if cancelled, was scheduled to take place.
|M
|
|-
|CARE CONTACT TIME
|The time at which a Care Contact took place.
|R
|
|-
|ADMINISTRATIVE CATEGORY CODE
|This is recorded for PATIENT ACTIVITY. A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare and can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS. The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded. The category 'amenity PATIENT' is only applicable to PATIENTS using a Hospital Bed.
|R
|01 - NHS PATIENT, including Overseas Visitors charged under the National Health Service (Overseas Visitors Hospital Charging Regulations)

02 - Private PATIENT, one who uses accommodation or services authorised under the National Health Service Act 2006

03 - Amenity PATIENT, one who pays for the use of a single room or small ward in accordance with the National Health Service Act 2006

04 - Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff.

98 - Not applicable

99 - ADMINISTRATIVE CATEGORY CODE not known
|-
|CLINICAL CONTACT DURATION OF CARE CONTACT
|The total duration of the direct clinical contact at a CARE CONTACT in minutes, excluding any administration time prior to or after the CARE CONTACT and the CARE PROFESSIONAL's travelling time to the CARE CONTACT. CLINICAL CONTACT DURATION OF CARE CONTACT includes the time spent on the different CARE ACTIVITIES that may be performed in a single CARE CONTACT. The duration of each CARE ACTIVITY is recorded in CLINICAL CONTACT DURATION OF CARE ACTIVITY. This should be recorded in minutes.
|R
|
|-
|CONSULTATION TYPE
|The type of consultation between the CARE PROFESSIONAL and the PATIENT.
|R
|01 - Initial Consultation

02 - Follow-up Consultation
|-
|CARE CONTACT SUBJECT
|The person who was the subject of the Care Contact.
|R
|01 - Patient

02 - Patient Proxy
|-
|CONSULTATION MECHANISM (MENTAL HEALTH)
|The communication mechanism used to relay information between the CARE PROFESSIONAL and the PERSON who is the subject of the consultation, during a CARE CONTACT. A non-face to face consultation should directly support diagnosis and care planning and must replace a face to face Out-Patient Attendance Consultant, Clinic Attendance Nurse or Clinic Attendance Midwife, or other types of CARE CONTACT. A record of the consultation must be retained in the PATIENT's records. Contact with PATIENTS solely for the purpose of informing them of the outcome of Diagnostic Test results, with no other clinical interaction, are not classified as CARE CONTACTS.
|R
|01 - Face to face

02 - Telephone

04 - Talk type for a person unable to speak

05 - Email

09 - Text Message (Asynchronous)

10 - Instant messaging (Synchronous)

11 - Video consultation

12 - Message Board (Asynchronous)

13 - Chat Room (Synchronous)

98 - Other (not listed)
|-
|ACTIVITY LOCATION TYPE CODE
|The type of LOCATION for an ACTIVITY: • where PATIENTS are seen • where SERVICES are provided or • from which requests for SERVICES are sent.
|R
|A01 Patient's home

A02 Carer's home

A03 Patient's workplace

A04 Other patient related location

B01 Primary Care Health Centre

B02 Polyclinic

C01 General Medical Practitioner Practice

C02 Dental Practice

C03 Ophthalmic Medical Practitioner premises

D01 Walk In Centre

D02 Out of Hours Centre

D03 Emergency Community Dental Service

E01 Out-Patient Clinic

E02 Ward

E03 Day Hospital

E04 Emergency Care Department or Minor Injuries Department

E99 Other departments

F01 Hospice

G01 Care Home Without Nursing

G02 Care Home With Nursing

G03 Children’s Home

G04 Integrated Care Home Without Nursing and Care Home With Nursing

H01 Day Centre

J01 Resource Centre

K01 Sure Start Children’s Centre

K02 Child Development Centre

L01 School

L02 Further Education College

L03 University

L04 Nursery Premises

L05 Other Childcare Premises

L06 Training Establishments

L99 Other Educational Premises

M01 Prison

M02 Probation Service Premises

M03 Police Station / Police Custody Suite

M04 Young Offender Institution

M06 Young Offender Institution (15-17)

M07 Young Offender Institution (18-21)

M05 Immigration Removal Centre

N01 Street or other public open space

N02 Other publicly accessible area or building

N03 Voluntary or charitable agency premises

N04 Dispensing Optician premises

N05 Dispensing Pharmacy premises

X01 Other locations not elsewhere classified

1 General Health Promotion Session

2 Telephone Support Sessiom

3 Thereputic Group Session
|-
|PLACE OF SAFETY INDICATOR
|An indication of whether a LOCATION is being used as a PLACE OF SAFETY.
|R
|Y - Yes – is being used as a Place of Safety

N - No – is not being used as a Place of Safety
|-
|ORGANISATION SITE IDENTIFIER (OF TREATMENT)
|The ORGANISATION IDENTIFIER of the Organisation Site where the PATIENT was treated.
|R
|
|-
|COMMUNITY PERINATAL MENTAL HEALTH PARTNER ASSESSMENT OFFER INDICATOR
|An indication of whether a Community Perinatal Mental Health Partner Assessment has been offered to the partner of a PERSON in contact with a Specialist Perinatal Mental Health Community Service.
|R
|Y - Yes - a Community Perinatal Mental Health Partner Assessment has been offered

N - No - a Community Perinatal Mental Health Partner Assessment has not been offered
|-
|PLANNED CARE CONTACT INDICATOR
|An indication as to whether a Care Contact is a result of a Planned Appointment.
|R
|Y - Yes - the care contact is a result of a planned Appointment

N - No - the care contact is not a result of a planned appointment
|-
|CARE CONTACT PATIENT THERAPY MODE
|The mode of therapy for the patient during a Care Contact.
|R
|1 - Individual patient

2 - Couple

3 - Group Therapy
|-
|ATTENDED OR DID NOT ATTEND CODE
|This indicates whether or not an APPOINTMENT for a CARE CONTACT took place. If the APPOINTMENT did not take place it also indicates whether or not advanced warning was given.
|R
|5 - Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT
6 - Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen

7 - Patient arrived late and could not be seen

2 - APPOINTMENT cancelled by, or on behalf of, the PATIENT

3 - Did not attend - no advance warning given

4 - Appointment cancelled or postponed by the health care provider
|-
|EARLIEST REASONABLE OFFER DATE
|The date of the earliest of the Reasonable Offers made to a PATIENT for an APPOINTMENT or Elective Admission.
|R
|
|-
|EARLIEST CLINICALLY APPROPRIATE DATE
|The earliest DATE that it was clinically appropriate for an ACTIVITY to take place.
|R
|
|-
|CARE CONTACT CANCELLATION DATE
|The date that a Care Contact was cancelled by the Provider or Patient.
|R
|
|-
|CARE CONTACT CANCELLATION REASON
|The reason that a Care Contact was cancelled.
|R
|01 - Cancelled for Clinical Reasons

02 - Cancelled for Non-clinical Reasons
|-
|REASONABLE ADJUSTMENT MADE INDICATOR
|Was a reasonable adjustment made for this patient?
|R
|Y - Yes - a Reasonable Adjustment was made for the patient

N - No - a Reasonable Adjustment was not made for the patient

X - Not applicable
|} 

=== Care Activity ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE ACTIVITY IDENTIFIER
|The unique identifier for a CARE ACTIVITY. It would normally be automatically generated by the local system upon recording a new activity, although could be manually assigned.
|M
|
|-
|CLINICAL CONTACT DURATION OF CARE ACTIVITY
|The duration of a CARE ACTIVITY in minutes, excluding any administration time prior to or after the CARE ACTIVITY and the CARE PROFESSIONAL's travelling time to the LOCATION where the CARE ACTIVITY was provided. This is calculated from the Start Time and End Time of the CARE ACTIVITY.
|R
|
|-
|CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.
|R
|
|-
|FINDING SCHEME IN USE (MENTAL HEALTH)
|The code scheme basis of a finding.
|R
|01 - ICD-10

04 - SNOMED CT®
|-
|CODED FINDING (CODED CLINICAL ENTRY)
|A unique identifier for a finding from a specific classification or clinical terminology.
|R
|
|-
|CODED OBSERVATION (SNOMED CT)
|A unique identifier for an observation from a specific clinical terminology.
|R
|
|-
|OBSERVATION VALUE
|The numeric value resulting from a clinical observation.
|R
|
|-
|UCUM UNIT OF MEASUREMENT
|The unit of measurement used to measure the result of a clinical observation. See <nowiki>http://unitsofmeasure.org/trac/</nowiki>.
|R
|
|} 

=== Other in Attendance ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|OTHER PERSON IN ATTENDANCE AT CARE CONTACT
|The other PERSON in attendance, with the PATIENT, at the CARE CONTACT.
|M
|01 - Independent Advocate (Family Member)

02 - Independent Advocate (Independent Person)

03 - Independent Mental Capacity Advocate (IMCA)

04 - Independent Mental Health Advocate (IMHA)

05 - Non-Instructed Advocate

10 - Parent or relative (Non-Advocate)

11 - Friend or neighbour (Non-Advocate)

12 - Care Worker (Non-Advocate)
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL CAPACITY ADVOCATE
|Reason the patient does not have an Independent Mental Capacity Advocate (IMCA) This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|01 - PATIENT has chosen not to have an Independent Mental Health Advocate

02 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and no further action taken

03 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is on a waiting list and an alternative SERVICE is being sought

04 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and no further action taken

05 - No locally commissioned Independent Mental Health Advocate available, the PATIENT is not on a waiting list and an alternative SERVICE is being sought

98 - Other (not listed)

99 - Not applicable (no requirement for an Independent Mental Capacity Advocate)
|-
|REASON PATIENT DOES NOT HAVE INDEPENDENT MENTAL HEALTH ADVOCATE
|Reason the patient does not have an Independent Mental Health Advocate (IMHA) This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|01 - Patient has chosen not to have an Independent Mental Health Advocate

02 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and no further action taken

03 - No locally commissioned Independent Mental Health Advocate available, the patient is on a waiting list and an alternative service is being sought

04 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and no further action taken

05 - No locally commissioned Independent Mental Health Advocate available, the patient is not on a waiting list and an alternative service is being sought

98 - Other (not listed)

99 - Not applicable (no requirement for an Independent Mental Health Advocate)
|} 

=== Indirect Activity ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|INDIRECT ACTIVITY DATE
|The date that the indirect activity took place
|M
|
|-
|INDIRECT ACTIVITY TIME
|The time that the indirect activity took place
|R
|
|-
|DURATION OF INDIRECT ACTIVITY
|The duration of the indirect activity in minutes, excluding any administration time prior to or after the indirect activity and the CARE PROFESSIONAL's travelling time to the LOCATION where the indirect activity was provided.
|R
|
|-
|CODED INDIRECT ACTIVITY PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
|The SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure. Allows the capture of indirect activity to be attributed.
|R
|
|} 

=== Group Session ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|GROUP SESSION IDENTIFIER
|The GROUP SESSION IDENTIFIER is used to uniquely identify the GROUP SESSION within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Group Session, although could be manually assigned.
|M
|
|-
|GROUP SESSION DATE
|The date that a Group Session took place, or, if cancelled, was scheduled to take place.
|M
|
|-
|CLINICAL CONTACT DURATION OF GROUP SESSION
|The duration of a Group Session in minutes, excluding any administration time prior to or after the Group Session and the CARE PROFESSIONAL's travelling time to the LOCATION where the Group Session was provided.
|R
|
|-
|GROUP SESSION TYPE (MENTAL HEALTH)
|The type of Group Session provided by a Mental Health Service.
|R
|01 - General Health Promotion Session

02 - Telephone Support Session

03 - Therapeutic Group Session
|-
|NUMBER OF GROUP SESSION PARTICIPANTS
|The number of persons who participated in the Group Session excluding the care professionals.
|R
|
|} 

=== Mental Health Drop In Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|MENTAL HEALTH DROP IN CONTACT IDENTIFIER
|The Mental Health DROP IN CONTACT IDENTIFIER is used to uniquely identify the Mental Health DROP IN CONTACT within the Health Care Provider. It would normally be automatically generated by the local system upon recording a new Drop In Contact, although could be manually assigned.
|M
|
|-
|CARE CONTACT DATE (MENTAL HEALTH DROP IN CONTACT)
|The date that a Drop In Contact took place.
|M
|
|-
|MENTAL HEALTH DROP IN CONTACT SERVICE TYPE
|The type of SERVICE where the Mental Health Drop In Contact took place.
|R
|A17 - Memory Services/Clinic/Drop In Service

A19 - 24/7 Crisis Response Line

A21 - Crisis Café/Safe Haven/Sanctuary Service
|-
|START TIME (MENTAL HEALTH DROP IN CONTACT)
|The Start Time of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|
|-
|END TIME (MENTAL HEALTH DROP IN CONTACT)
|The End Time of the Mental Health Drop In Contact as reported by the Care Professional.
|R
|
|} 

=== Mental Health Act Legal Status Classification Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
|A unique identifier allocated to each Mental Health Act Legal Status Classification Assignment Period.
|M
|
|-
|START DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The Start Date of the Mental Health Act Legal Status Classification Assignment Period.
|M
|
|-
|START TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The Start Time of the Mental Health Act Legal Status Classification Assignment Period.
|M
|
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON
|The reason for the start of the current Mental Health Act Legal Status Classification Assignment Period.
|R
|01 - Change in Mental Health Act Legal Status Classification Code (including from informal)

04 - Transfer from other Health Care Provider
|-
|EXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|The date when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|
|-
|EXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
|The time which the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION for a patient expires.
|R
|
|-
|END DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The date on which the Mental Health Act Legal Status Classification Assignment Period ended.
|R
|
|-
|END TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
|The time on which the Mental Health Act Legal Status Classification Period ended.
|R
|
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON
|The reason for the end of the Mental Health Act Legal Status Classification Assignment Period.
|R
|01 - Change in Mental Health Act Legal Status Classification Code (including to informal)

04 - Transfer to other Health Care Provider

05 - Death of patient
|-
|MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
|'A code to identify the classification of Mental Health Act Legal Status.
|R
|01 - Informal

02 - Formally detained under Mental Health Act Section 2

03 - Formally detained under Mental Health Act Section 3

04 - Formally detained under Mental Health Act Section 4

05 - Formally detained under Mental Health Act Section 5 (2)

06 - Formally detained under Mental Health Act Section 5 (4)

07 - Formally detained under Mental Health Act Section 35

08 - Formally detained under Mental Health Act Section 36

09 - Formally detained under Mental Health Act Section 37 with section 41 restrictions

10 - Formally detained under Mental Health Act Section 37

12 - Formally detained under Mental Health Act Section 38

13 - Formally detained under Mental Health Act Section 44

14 - Formally detained under Mental Health Act Section 46

15 - Formally detained under Mental Health Act Section 47 with section 49 restrictions

16 - Formally detained under Mental Health Act Section 47

17 - Formally detained under Mental Health Act Section 48 with section 49 restrictions

18 - Formally detained under Mental Health Act Section 48

19 - Formally detained under Mental Health Act Section 135

20 - Formally detained under Mental Health Act Section 136

31 - Formally detained under Criminal Procedure (Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991

32 - Formally detained under other acts

35 - Subject to guardianship under Mental Health Act Section 7

36 - Subject to guardianship under Mental Health Act Section 37

37 - Formally detained under Mental Health Act Section 45A (Limited direction in force)

38 - Formally detained under Mental Health Act Section 45A (Limitation direction ended)

98 - Not Applicable

99 - Not Known
|-
|MENTAL HEALTH ACT 2007 MENTAL CATEGORY
|The primary reason for the detention of PATIENTS.
|R
|A - Mental disorder (Learning Disability not present or not primary reason for using Act)

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

8 - Not applicable (i.e. not detained)

9 - Not Known (Not Recorded)
|} 

=== Mental Health Responsible Clinician Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
|The start date of an assignment of a Mental Health Responsible Clinician to a patient.
|M
|
|-
|END DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
|The end date of an assignment of a Mental Health Responsible Clinician to a patient.
|R
|
|} 

=== Conditional Discharge ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
|The start date of the Mental Health Conditional Discharge Period.
|M
|
|-
|END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
|The end date of the Mental Health Conditional Discharge Period.
|R
|
|-
|MENTAL HEALTH CONDITIONAL DISCHARGE END REASON
|The reason a Mental Health Conditional Discharge Period ended.
|R
|01 - Mental Health absolute discharge

02 - Recall of PATIENT

03 - Death of PATIENT
|-
|MENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY
|The body or PERSON responsible for granting Mental Health Absolute Discharge.
|R
|01 - Mental Health Tribunal

02 - Secretary of State
|} 

=== Community Treatment Order Recall ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (COMMUNITY TREATMENT ORDER RECALL)
|The start date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|M
|
|-
|EXPIRY DATE (COMMUNITY TREATMENT ORDER RECALL)
|The date which the Community Treatment Order for a patient was due to expire. This should be updated following the extension of a Community Treatment Order. NB - This data item should only be recorded where the Community Treatment Order for the patient has been extended
|R
|
|-
|END DATE (COMMUNITY TREATMENT ORDER RECALL)
|The end date for a period of Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|R
|
|-
|COMMUNITY TREATMENT ORDER END REASON
|The reason for the termination of a period of a Community Treatment Order.
|R
|01 - Patient discharged

02 - Community Treatment Order revoked

03 - Patient died

04 - Patient transferred outside England

05 - Patient transferred to another Health Care Provider
|} 

=== Community Treatment Order Recall ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START TIME (COMMUNITY TREATMENT ORDER RECALL)
|The start time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|M
|
|-
|END TIME (COMMUNITY TREATMENT ORDER RECALL)
|The end time for a period of recall to hospital for treatment for a patient on a Community Treatment Order under S17A of the Mental Health Act 1983 (as amended by the Mental Health Act 2007).
|R
|
|} 

=== Hospital Provider Spell ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|HOSPITAL PROVIDER SPELL IDENTIFIER
|A unique identifier for each Hospital Provider Spell for a Health Care Provider.
|M
|
|-
|DECIDED TO ADMIT DATE
|The date a DECISION TO ADMIT was made.
|R
|
|-
|DECIDED TO ADMIT TIME
|The time a DECISION TO ADMIT was made.
|R
|
|-
|START DATE (HOSPITAL PROVIDER SPELL)
|The start date of a Hospital Provider Spell.
|M
|
|-
|START TIME (HOSPITAL PROVIDER SPELL)
|The start time of a Hospital Provider Spell.
|R
|
|-
|ADMISSION SOURCE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|The source of admission to a Hospital Provider Spell.
|R
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential Educational Establishments)

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

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

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Emergency Care Department

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

87 - Independent Sector Healthcare Provider run hospital

88 - Hospice

98 - Not applicable

99 - Not Known
|-
|METHOD OF ADMISSION (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|The method of admission to a Hospital Provider Spell.Note: see ELECTIVE ADMISSION TYPE for a full definition of Elective Admission.
|R
|11 - Elective Admission: Waiting list

12 - Elective Admission: Booked

13 - Elective Admission: Planned

21 - Emergency Admission: Emergency Care Department or acute or emergency dental SERVICE

22 - Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy

23 - Emergency Admission: Bed bureau

24 - Emergency Admission: Consultant Clinic, of this or another Health Care Provider

25 - Emergency Admission: Admission via Mental Health Crisis Resolution Team

2A - Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted

2B - Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency

2D - Emergency Admission: Other emergency admission

81 - Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency

98 - Not applicable

99 - Not Known
|-
|POSTCODE OF MAIN VISITOR
|The POSTCODE of the ADDRESS of the PATIENT's main visitor with ADDRESS ASSOCIATION TYPE 'Main Permanent Residence' or 'Other Permanent Residence', where the patient is being treated as part of a Hospital Provider Spell.
|R
|
|-
|ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|The estimated discharge date from a Hospital Provider Spell.
|R
|
|-
|PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|The planned discharge date from a Hospital Provider Spell.
|R
|
|-
|PLANNED DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|The planned destination of a PATIENT on completion of a Hospital Provider Spell.
|R
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)

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

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

48 - High Security Psychiatric Hospital, Scotland

49 - NHS other Hospital Provider - high security psychiatric accommodation

50 - NHS other Hospital Provider - medium secure unit

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

79 - PATIENT died or stillbirth

84 - Independent Sector Healthcare Provider run hospital - medium secure unit

87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit

88 - Hospice

89 - ORGANISATION responsible for forced repatriation

98 - Not applicable

99 - Not known
|-
|DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
|The discharge date from a Hospital Provider Spell.
|R
|
|-
|DISCHARGE TIME (HOSPITAL PROVIDER SPELL)
|The discharge time from a Hospital Provider Spell.
|R
|
|-
|METHOD OF DISCHARGE (MENTAL HEALTH HOSPITAL PROVIDER SPELL)
|The method of discharge from a Hospital Provider Spell.
|R
|1 - Patient discharged on clinical advice or with clinical consent

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

4 - Patient died

6 - Patient discharged him/herself

7 - Patient discharged by a relative or advocate

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

9 - Method of Discharge not known
|-
|DESTINATION OF DISCHARGE (HOSPITAL PROVIDER SPELL)
|The destination of a PATIENT on completion of a Hospital Provider Spell, or a note that the PATIENT died.
|R
|19 - Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by Local Authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode.

29 - Temporary place of residence when usually resident elsewhere (includes hotel, residential Educational Establishment)

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

37 - Court

40 - Penal establishment

42 - Police Station / Police Custody Suite

48 - High Security Psychiatric Hospital, Scotland

49 - NHS other Hospital Provider - high security psychiatric accommodation

50 - NHS other Hospital Provider - medium secure unit

51 - NHS other Hospital Provider - WARD for general PATIENTS or the younger physically disabled

52 - NHS other Hospital Provider - WARD for maternity PATIENTS or Neonates

53 - NHS other Hospital Provider - WARD for PATIENTS who are mentally ill or have Learning Disabilities

55 - Care Home With Nursing

56 - Care Home Without Nursing

66 - Local Authority foster care

79 - PATIENT died or stillbirth

84 - Independent Sector Healthcare Provider run hospital - medium secure unit

87 - Independent Sector Healthcare Provider run hospital - excluding medium secure unit

88 - Hospice

89 - ORGANISATION responsible for forced repatriation

98 - Not applicable

99 - Not known
|-
|POSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)
|The POSTCODE of the ADDRESS of a PATIENTS's destination on completion of a Hospital Provider Spell.
|R
|
|-
|TRANSFORMING CARE INDICATOR
|Indicator to show if the patient is in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|Y - Yes - Patient is in scope of transforming care

N - No - Patient is not in scope of transforming care
|-
|TRANSFORMING CARE CATEGORY
|Category of patients in scope of Transforming Care This only needs to be captured for inpatients that are in scope of Transforming Care
|R
|1 - Patient with autism (and no learning disability)

2 - Patient with a learning disability (and no autism)

3 - Patient with autism and a learning disability
|} 

=== Ward Stay ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|WARD STAY IDENTIFIER
|A unique identifier allocated for each Ward Stay during the hospital provider spell.
|M
|
|-
|START DATE (WARD STAY)
|The start date of a ward stay.
|M
|
|-
|START TIME (WARD STAY)
|The start time of a ward stay.
|R
|
|-
|END DATE (MENTAL HEALTH TRIAL LEAVE)
|The End Date of a period of Mental Health Trial Leave for a PATIENT.
|R
|
|-
|END DATE (WARD STAY)
|The end date of a ward stay.
|R
|
|-
|END TIME (WARD STAY)
|The end time of a ward stay.
|R
|
|-
|WARD SETTING TYPE (MENTAL HEALTH)
|The type of WARD setting for a Mental Health Service's PATIENT during a Hospital Provider Spell.
|R
|01 - Child and Adolescent Mental Health Ward

02 - Paediatric Ward

03 - Adult Mental Health Ward

04 - Non Mental Health Ward

05 - Learning Disabilities Ward

06 - Older People's Mental Health Ward
|-
|INTENDED AGE GROUP (MENTAL HEALTH)
|The age group of PATIENTS intended to use a WARD indicated in the operational plan.
|R
|10 - Child only

11 - Adolescent only

12 - Child and Adolescent

13 - Adult only

14 - Older Adult only

15 - Adult and Older Adult

99 - Any age
|-
|SEX OF PATIENTS CODE (MENTAL HEALTH)
|The intended SEX of PATIENTS for the ward as indicated in the operational plan in which the patient is placed.
|R
|1 - Male

2 - Female

8 - Not specified
|-
|INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH)
|The intended level of resources and intensity of care for the ward in which the person is placed.
|R
|51 - Mental Illness intensive care: specially designated ward for Patients needing containment and more intensive management (e.g. Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where Patients may require one to one nursing while on a standard ward

52 - Mental Illness short stay: Patients intended to stay less than a year

53 - Mental Illness long stay: Patients intended to stay a year or more

61 - Learning Disability Patients in a designated or interim secure unit

62 - Learning Disability Patients intending to stay less than a year

63 - Learning Disability Patients intending to stay a year or more
|-
|WARD SECURITY LEVEL
|The level of security for a ward.
|R
|0 - General (non-secure)

1 - Low Secure

2 - Medium Secure

3 - High Secure
|-
|LOCKED WARD INDICATOR
|An indication of whether a WARD is locked. For the Mental Health Services Data Set, LOCKED WARD INDICATOR indicates whether a WARD which is used to provide care by a Mental Health Service, and has a WARD SECURITY LEVEL National Code "General (non-secure)", is locked to prevent unauthorised entry and/or exit.
|R
|Y - Yes - is a locked WARD

N - No - is not a locked WARD
|-
|MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
|The classification of the admitted PATIENT during a Ward Stay.
|R
|10 - Acute adult mental health care

11 - Acute older adult mental health care (organic and functional)

12 - Adult Psychiatric Intensive Care Unit (acute mental health care)

13 - Adult Eating Disorders

14 - Mother and baby

15 - Adult Learning Disabilities

17 - Adult High dependency rehabilitation

19 - Adult Low secure

20 - Adult Medium secure

21 - Adult High secure

22 - Adult Neuro-psychiatry / Acquired Brain Injury

23 - General child and young PERSON admitted PATIENT - Child (including High Dependency)

24 - General child and young PERSON admitted PATIENT - Young PERSON (including High Dependency)

25 - Eating Disorders admitted patient - Young person (13 years and over)

26 - Eating Disorders admitted patient - Child (12 years and under)

27 - Child and Young Person Low Secure Mental Illness

28 - Child and Young Person Medium Secure Mental Illness

29 - Child Mental Health admitted patient services for the Deaf

30 - Child and Young Person Learning Disabilities / Autism admitted patient

31 - Child and Young Person Low Secure Learning Disabilities

32 - Child and Young Person Medium Secure Learning Disabilities

33 - Severe Obsessive Compulsive Disorder and Body Dysmorphic Disorder - Young person

34 - Child and Young Person Psychiatric Intensive Care Unit

35 - Adult admitted patient continuing care

36 - Adult community rehabilitation unit

37 - Adult highly specialist high dependency rehabilitation unit

38 - Adult longer term high dependency rehabilitation unit

39 - Adult mental health admitted patient services for the Deaf

40 - Adult personality disorder
|-
|WARD CODE
|A unique identification of a WARD within a Health Care Provider.
|R
|
|} 

=== Assigned Care Professional ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|The start date of an assignment of a Care Professional responsible for the care of the patient.
|M
|
|-
|END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
|The end date of an assignment of a Care Professional responsible for the care of the patient.
|R
|
|-
|TREATMENT FUNCTION CODE (MENTAL HEALTH)
|'This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE or a different TREATMENT FUNCTION which will be the CARE PROFESSIONAL's treatment interest.
|R
|319 Respite Care Service

348 Post-COVID-19 Syndrome Service

656 Clinical Psychology Service

700 Learning Disability Service

710 Adult Mental Health Service

711 Child and Adolescent Psychiatry Service

712 Forensic Psychiatry Service

713 Medical Psychotherapy Service

715 Old Age Psychiatry Service

720 Eating Disorders Service

721 Addiction Service

722 Liaison Psychiatry Service

723 Psychiatric Intensive Care Service

724 Perinatal Mental Health Service

725 Mental Health Recovery and Rehabilitation Service

726 Mental Health Dual Diagnosis Service

727 Dementia Assessment Service

730 Neuropsychiatry Service
|} 

=== Mental Health Delayed Discharge ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|The date that the clinical decision was taken that the PATIENT is fit and ready for discharge, but external factors prevent the discharge taking place.
|M
|
|-
|END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
|The date that a period of delayed discharge for a patient who had previously been ready for discharge ended. This may end because the patient was discharged or because the patient was no longer ready for discharge.
|R
|
|-
|MENTAL HEALTH DELAYED DISCHARGE REASON
|The reason that a patient was not able to be discharged despite being medically ready for discharge.
|R
|A2 - Awaiting care coordinator allocation

B1 - Awaiting public funding

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

D1 - Awaiting Care Home Without Nursing placement or availability

D2 - Awaiting Care Home With Nursing placement or availability

E1 - Awaiting care package in own home

F2 - Awaiting community equipment, telecare and/or adaptations

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

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

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

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

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

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

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

G9 - Patient or Family choice - Supported accommodation

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

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

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

H1 - Disputes

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

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

J2 - Housing - Awaiting supported accommodation

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

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

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

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

P1 - Awaiting residential special school or college placement or availability

Q1 - Lack of local education support

R1 - Public safety concern unrelated to clinical treatment need (care team)

R2 - Public safety concern unrelated to clinical treatment need (Ministry of Justice)

S1 - No lawful community care package available

T1 - Lack of health care service provision

T2 - Lack of social care support

98 - No reason given
|-
|MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE
|An indication to which ORGANISATION the Mental Health Delayed Discharge Period is attributable.
|R
|04 - NHS, excluding housing

05 - Social Care, excluding housing

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

07 - Housing (including supported/specialist housing)
|-
|ORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE)
|The Local Authority responsible for the social care attributed Mental Health Delayed Discharge Period.
|R
|
|} 

=== Restrictive Intervention Incident ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|RESTRICTIVE INTERVENTION INCIDENT IDENTIFIER
|A unique identifier allocated for each Restrictive Intervention Incident during the Hospital Provider Spell
|M
|
|-
|START DATE (RESTRICTIVE INTERVENTION INCIDENT)
|The Start Date of the Restrictive Intervention Incident as reported by the Care Professional.
|M
|
|-
|START TIME (RESTRICTIVE INTERVENTION INCIDENT)
|The Start Time of the Restrictive Intervention Incident as reported by the Care Professional.
|R
|
|-
|END DATE (RESTRICTIVE INTERVENTION INCIDENT)
|The End Date of the Restrictive Intervention Incident as reported by the Care Professional.
|R
|
|-
|END TIME (RESTRICTIVE INTERVENTION INCIDENT)
|The End Time of the Restrictive Intervention Incident as reported by the Care Professional.
|R
|
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT)
|An indication of whether a Restrictive Intervention Post-Incident Review for the PATIENT was held within 48 hours of the incident of a Restrictive Intervention.
|R
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT)
|The reason why a Restrictive Intervention Post-Incident Review for the PATIENT was not held within 48 hours of the incident of a Restrictive Intervention.
|R
|1 - Clinical decision to delay

2 - Patient refused to take part

3 - Other (not listed)
|-
|RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL)
|An indication of whether a Restrictive Intervention Post-Incident Review for Care Personnel was held within 24 hours of the incident of a Restrictive Intervention.
|R
|Y - Yes - a Restrictive Intervention Post-Incident Review was held for a Restrictive Intervention

N - No - a Restrictive Intervention Post-Incident Review was not held for a Restrictive Intervention
|-
|RESTRICTIVE INTERVENTION REASON
|The reason that a Restrictive Intervention was used on a PATIENT during a Hospital Provider Spell.
|R
|10 - Prevent a patient being violent to others

11 - Prevent a patient causing serious intentional harm to themselves

12 - Prevent a patient causing serious physical injury to themselves by accident

13 - Lawfully administer medicines or other medical treatment

14 - Facilitate personal care

15 - Facilitate nasogastric (NG) feeding

16 - Prevent the patient exhibiting extreme and prolonged over-activity

17 - Prevent the PATIENT exhibiting otherwise dangerous behaviour

18 - Undertake a search of the patient’s clothing or property to ensure the safety of others

19 - Prevent the patient absconding from lawful custody

98 - Other (not listed)

99 - Not Known (Not Recorded)
|} 

=== Restrictive Intervention Type ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|RESTRICTIVE INTERVENTION TYPE IDENTIFIER
|A unique identifier allocated for each Restrictive Intervention Type during the Hospital Provider Spell
|M
|
|-
|START DATE (RESTRICTIVE INTERVENTION TYPE)
|The Start Date of the Restrictive Intervention Type as reported by the Care Professional.
|M
|
|-
|START TIME (RESTRICTIVE INTERVENTION TYPE)
|The Start Time of the Restrictive Intervention Type as reported by the Care Professional.
|R
|
|-
|RESTRICTIVE INTERVENTION TYPE
|Type of RESTRICTIVE INTERVENTION used.
|R
|01 - Physical restraint - Prone

07 - Physical restraint - Standing

08 - Physical restraint - Restrictive escort

09 - Physical restraint - Supine

10 - Physical restraint - Side

11 - Physical restraint - Seated

12 - Physical restraint - Kneeling

13 - Physical restraint - Other (not listed)

14 - Chemical restraint - Injection (Rapid Tranquillisation)

15 - Chemical restraint - Injection (Non Rapid Tranquillisation)

16 - Chemical restraint - Oral

17 - Chemical restraint - Other (not listed)

04 - Mechanical restraint

05 - Seclusion

06 - Segregation
|-
|END DATE (RESTRICTIVE INTERVENTION TYPE)
|The End Date of the Restrictive Intervention Type as reported by the Care Professional.
|R
|
|-
|END TIME (RESTRICTIVE INTERVENTION TYPE)
|The End Time of the Restrictive Intervention Type as reported by the Care Professional.
|R
|
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT)
|An indication of whether an injury was sustained to the PATIENT during an incident of restraint during a Restrictive Intervention.
|R
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL)
|An indication of whether an injury was sustained to a member of Care Personnel during an incident of restraint during a Restrictive Intervention.
|R
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|-
|RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON)
|An indication of whether an injury was sustained to a person, other than the PATIENT or Care Personnel, during an incident of restraint during a Restrictive Intervention.
|R
|Y - Yes - an injury was sustained during an incident of restraint during a Restrictive Intervention

N - No - no injury was sustained during an incident of restraint during a Restrictive Intervention
|} 

=== Police Assistance Request ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|POLICE ASSISTANCE REQUEST DATE
|The date the call was made to request police assistance
|M
|
|-
|POLICE ASSISTANCE REQUEST TIME
|The time the call was made to request police assistance
|R
|
|-
|POLICE ASSISTANCE ARRIVAL DATE
|The date the Police arrived following the request for assistance
|R
|
|-
|POLICE ASSISTANCE ARRIVAL TIME
|The time the Police arrived following the request for assistance
|R
|
|-
|POLICE RESTRAINT OR FORCE USED INDICATOR
|An indication of whether the police used restraint or force on a PATIENT.
|R
|Y - Yes - the police used restraint or force on a PATIENT

N - No - the police did not use restraint or force on a PATIENT
|} 

=== Assault ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DATE OF ASSAULT ON PATIENT
|The DATE that an instance of assault on the PATIENT by another PATIENT occurred.
|M
|
|} 

=== Self-Harm ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DATE OF SELF-HARM
|The date that an incident of self-harm for the patient occurred.
|M
|
|-
|OBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE)
|The date that evidence of current substance misuse by a PATIENT was observed by a CARE PROFESSIONAL.
|M
|
|} 

=== Home Leave ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (HOME LEAVE)
|The start date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|M
|
|-
|START TIME (HOME LEAVE)
|The start time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|
|-
|END DATE (HOME LEAVE)
|The end date for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|
|-
|END TIME (HOME LEAVE)
|The end time for a period of Home Leave for patients NOT liable for detention under the Mental Health Act 1983.
|R
|
|} 

=== Leave Of Absence ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|The start date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|M
|
|-
|START TIME (MENTAL HEALTH LEAVE OF ABSENCE)
|The start time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|R
|
|-
|END DATE (MENTAL HEALTH LEAVE OF ABSENCE)
|The end date of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|R
|
|-
|END TIME (MENTAL HEALTH LEAVE OF ABSENCE)
|The end time of a period of Mental Health Leave Of Absence for a PATIENT detained under the Mental Health Acts 1983 as amended by the Mental Health (Patients in the Community) Act 1995.
|R
|
|-
|MENTAL HEALTH LEAVE OF ABSENCE END REASON
|The reason a Mental Health Leave of Absence ended.
|R
|01 - Patient returned on or before day specified

02 - Leave revoked and patient recalled by Mental Health Responsible Clinician

03 - Period of leave to be extended

04 - Patient failed to return on or before day specified and is absent without leave

05 - Patient's liability for detention terminated by Mental Health Responsible Clinician

06 - Patient's liability for detention terminated by Mental Health Act Review Tribunal

07 - Patient's liability for detention terminated by Hospital Managers

08 - Patient died

96 - Other (not listed)

99 - MENTAL HEALTH LEAVE OF ABSENCE END REASON Not Known (Not Recorded)
|-
|ESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR
|An indication of whether a period of Mental Health Leave Of Absence is escorted or unescorted.
|R
|Y - Yes - a period of Mental Health Leave of Absence is escorted

N - No - a period of Mental Health Leave of Absence is not escorted
|} 

=== Mental Health Trial Leave ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (MENTAL HEALTH TRIAL LEAVE)
|The Start Date of a period of Mental Health Trial Leave for a PATIENT.
|M
|
|-
|START TIME (MENTAL HEALTH TRIAL LEAVE)
|The Start Time of a period of Mental Health Trial Leave for a PATIENT.
|R
|
|-
|END TIME (MENTAL HEALTH TRIAL LEAVE)
|The End Time of a period of Mental Health Trial Leave for a PATIENT.
|R
|
|} 

=== Hospital Provider Spell Commissioner Assignment Period ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (COMMISSIONER ASSIGNMENT PERIOD)
|The Start Date of the Commissioner Assignment Period.
|M
|
|-
|END DATE (COMMISSIONER ASSIGNMENT PERIOD)
|The End Date of the Commissioner Assignment Period.
|R
|
|} 

=== Specialised Mental Health Exceptional Package of Care ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE CHARGE
|The amount charged for the SMH EPC in the reporting period
|M
|
|-
|START DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|The start date of an SMH EPC.
|M
|
|-
|END DATE (SPECIALISED MENTAL HEALTH EXCEPTIONAL PACKAGE OF CARE)
|The End Date of an SMH EPC.
|R
|
|} 

=== Medical History (Previous Diagnosis) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DIAGNOSIS SCHEME IN USE (MENTAL HEALTH)
|The code scheme basis of the Diagnosis.
|M
|02 - ICD-10

06 - SNOMED CT®
|-
|PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
|A unique identifier for a clinical diagnosis from a specific classification or clinical terminology.
|M
|
|-
|CODED DIAGNOSIS TIMESTAMP
|The date, time and time zone for the PATIENT DIAGNOSIS.
|R
|
|} 

=== Provisional Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
|This is the provisional DIAGNOSIS of the PATIENT, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare.
|M
|
|} 

=== Primary Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY)
|This is the primary diagnosis of the patient, from a specific classification or clinical terminology, for the main condition treated or investigated during the relevant episode of healthcare, and where there is no definitive diagnosis, the main symptom, abnormal findings or problem.
|M
|
|}
 

=== Secondary Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY)
|This is any other diagnosis other than the primary diagnosis, from a specific classification or clinical terminology. Multiple Secondary Diagnoses may be recorded.
|M
|
|-
|CODED DIAGNOSIS TIMESTAMP
|The date, time and time zone for the PATIENT DIAGNOSIS.
|R
|
|}
 

=== Coded Scored Assessment (Referral) ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CODED ASSESSMENT TOOL TYPE (SNOMED CT)
|The SNOMED CT concept ID which is used to identify an assessment in SNOMED CT.
|M
|
|-
|PERSON SCORE
|The observable value (score) resulting from an assessment.
|M
|
|-
|ASSESSMENT TOOL COMPLETION TIMESTAMP
|The date, time and time zone on which the assessment took place
|M
|
|}
 

=== Care Programme Approach (CPA) Care Episode ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER
|A unique identifier allocated to each Care Programme Approach Care Episode.
|M
|
|-
|START DATE (CARE PROGRAMME APPROACH CARE)
|The start date for Care Programme Approach Care for the patient.
|M
|
|-
|END DATE (CARE PROGRAMME APPROACH CARE)
|The end date for Care Programme Approach Care for the patient.
|R
|
|}
 

=== Care Programme Approach (CPA) Review ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PROGRAMME APPROACH REVIEW DATE
|The date of the Care Programme Approach review.
|M
|
|}
 

=== Clustering Tool Assessment ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CLUSTERING TOOL ASSESSMENT IDENTIFIER
|A unique identifier for each clustering tool assessment that takes place for each patient.
|M
|
|-
|CLUSTERING TOOL ASSESSMENT CATEGORY
|The category of the clustering tool assessment completed.
|M
|01 - Adult Mental Health Clustering Tool

03 - Learning Disabilities Clustering Tool

04 - Forensic Mental Health Clustering Tool

05 - Forensic Learning Disabilities Clustering Tool

06 - Child and Adolescent Mental Health Needs Based Grouping Tool
|-
|ASSESSMENT TOOL COMPLETION DATE
|The date on which a clustering tool assessment was completed for a patient.
|M
|
|-
|ASSESSMENT TOOL COMPLETION TIME
|The time on which a clustering tool assessment was completed for a patient.
|R
|
|-
|CLUSTERING TOOL ASSESSMENT REASON
|The reason that the clustering tool assessment for the patient was undertaken.
|R
|10 - Initial assessment

11 - Scheduled re-assessment

12 - Re-assessment following significant unanticipated change in need

97 - Other Reason (not listed)

99 - CLUSTERING TOOL ASSESSMENT REASON Not Known (Not Recorded)
|-
|MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE
|The 'Mental Health Care Cluster Super Class' to which the patient has been assigned by the professional following completion of a clustering tool assessment but prior to Care Cluster allocation.
|R
|A - Non-Psychotic

B - Psychotic

C - Organic

Z - Unable to assign patient to Mental Health Care Cluster Super Class
|-
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL)
|ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) is the initial allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL, without reference to the National Tariff Payment System clustering algorithm.
|R
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)

02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)

04 - Care Cluster 4 - Non-Psychotic (Severe)

05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.

10 - Care Cluster 10 - First Episode Psychosis

11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14 - Psychotic Crisis

15 - Care Cluster 15 - Severe Psychotic Depression

16 - Care Cluster 16 - Dual Diagnosis

17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18 - Cognitive Impairment (Low Need)

19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)

21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)
|-
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
|LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) is the initial allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|}
 

=== Care Cluster ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|The date on which the assignment of a patient to a Care Cluster started.
|M
|
|-
|START TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The time on which the assignment of a patient to a Care Cluster started.
|R
|
|-
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the ADULT MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL. The determination of the ADULT MENTAL HEALTH CARE CLUSTER CODE may or may not have involved the use of the National Tariff Payment System clustering algorithm.
|R
|00 - Care Cluster 0 - Variance (unable to assign ADULT MENTAL HEALTH CARE CLUSTER CODE)

01 - Care Cluster 1 - Common Mental Health Problems (Low Severity)

02 - Care Cluster 2 - Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3 - Non-Psychotic (Moderate Severity)

04 - Care Cluster 4 - Non-Psychotic (Severe)

05 - Care Cluster 5 - Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6 - Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7 - Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8 - Non-Psychotic Chaotic and Challenging Disorders

09 - Care Cluster 9 - Cluster Under Review - Note: This CARE CLUSTER is under review and should not be used.

10 - Care Cluster 10 - First Episode Psychosis

11 - Care Cluster 11 - Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12 - Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13 - Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14 - Psychotic Crisis

15 - Care Cluster 15 - Severe Psychotic Depression

16 - Care Cluster 16 - Dual Diagnosis

17 - Care Cluster 17 - Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18 - Cognitive Impairment (Low Need)

19 - Care Cluster 19 - Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20 - Cognitive Impairment or Dementia Complicated (High Need)

21 - Care Cluster 21 - Cognitive Impairment or Dementia Complicated (High Physical or Engagement)
|-
|CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE
|The Child and Adolescent Mental Health Needs Based Grouping code allocated to the child or young person by the CARE PROFESSIONAL.
|R
|10 - Getting Advice: Neurodevelopmental Assessment (NEU)

11 - Getting Advice: Signposting and Self-management Advice (ADV)

12 - Getting Help: Attention Deficit Hyperactivity Disorder (ADHD)

13 - Getting Help: Autism (AUT)

14 - Getting Help: Behavioural and/or Conduct Disorders (BEH)

15 - Getting Help: Bipolar Disorder (BIP)

16 - Getting Help: Depression (DEP)

17 - Getting Help: Generalised Anxiety Disorder and/or Panic Disorder (GAP)

18 - Getting Help: Obsessive compulsive disorder (OCD)

19 - Getting Help: Post-traumatic stress disorder (PTS)

20 - Getting Help: Self-harm (SHA)

21 - Getting Help: Social Anxiety Disorder (SOC)

22 - Getting Help: Co-occurring Behavioural and Emotional Difficulties (BEM)

23 - Getting Help: Co-occurring Emotional Difficulties (EMO)

24 - Getting Help: Difficulties Not Covered by Other Groupings (DNC)

25 - Getting More Help: Eating Disorders (EAT)

26 - Getting More Help: Presentation Suggestive of Potential Borderline Personality Disorder (PBP)

27 - Getting More Help: Psychosis (PSY)

28 - Getting More Help: Difficulties of Severe Impact (DSI)
|-
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL)
|FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC MENTAL HEALTH CARE CLUSTER CODE by the CARE PROFESSIONAL.
|R
|00 - Care Cluster 0: Variance

01 - Care Cluster 1: Common Mental Health Problems (Low Severity)

02 - Care Cluster 2: Common Mental Health Problems (Low Severity with Greater Need)

03 - Care Cluster 3: Non-Psychotic (Moderate Severity)

04 - Care Cluster 4: Non-Psychotic (Severe)

05 - Care Cluster 5: Non-Psychotic Disorders (Very Severe)

06 - Care Cluster 6: Non-Psychotic Disorder of Over-Valued Ideas

07 - Care Cluster 7: Enduring Non-Psychotic Disorders (High Disability)

08 - Care Cluster 8: Non-Psychotic Chaotic and Challenging Disorders

08b - Care Cluster 8b: Non Psychotic, Challenging and Anti-Social Disorders

10 - Care Cluster 10: First Episode Psychosis

11 - Care Cluster 11: Ongoing Recurrent Psychosis (Low Symptoms)

12 - Care Cluster 12: Ongoing or Recurrent Psychosis (High Disability)

13 - Care Cluster 13: Ongoing or Recurrent Psychosis (High Symptoms and Disability)

14 - Care Cluster 14: Psychotic Crisis

15 - Care Cluster 15: Severe Psychotic Depression

16 - Care Cluster 16: Dual Diagnosis

17 - Care Cluster 17: Psychosis and Affective Disorder (Difficult to Engage)

18 - Care Cluster 18: Cognitive Impairment (Low Need)

19 - Care Cluster 19: Cognitive Impairment or Dementia Complicated (Moderate Need)

20 - Care Cluster 20: Cognitive Impairment or Dementia (High Need)

21 - Care Cluster 21: Cognitive Impairment or Dementia (High Physical or Engagement)
|-
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
|FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) is the final allocation of the FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE by the CARE PROFESSIONAL.
|P
|
|-
|END DATE (CARE CLUSTER ASSIGNMENT PERIOD)
|The date on which the assignment of a patient to a Care Cluster ended.
|R
|
|-
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The time on which the assignment of a patient to a Care Cluster ended.
|R
|
|}
 

=== Five Forensic Pathways ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT DATE
|The date on which a Five Forensic Pathways assessment was completed for a patient.
|M
|
|-
|FIVE FORENSIC PATHWAYS ASSESSMENT REASON
|The reason for which a Five Forensic Pathways assessment was undertaken.
|R
|10 - Initial Assessment

11 - Scheduled Re-Assessment

12 - Re-Assessment following significant unanticipated change in need

97 - Other Reason (not listed)

99 - Not Known (Not Recorded)
|-
|FIVE FORENSIC PATHWAYS CODE
|The Five Forensic Pathway assigned to a patient.
|M
|0 - Unable to assign patient to one of the five forensic pathways

1 - Treatment responsive group

2 - Treatment resistant group – challenging behaviour

3 - Treatment resistant group – continuing care

4 - Personality disorder group – prison transfer

5 - Personality disorder group – co-morbidity
|}
 

=== Care Professionals ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PROFESSIONAL REGISTRATION BODY CODE
|A code which identifies the PROFESSIONAL REGISTRATION BODY.
|R
|01 - General Chiropractic Council

02 - General Dental Council

03 - General Medical Council

04 - General Optical Council

05 - Social Care Wales

08 - Health and Care Professions Council

09 - Nursing and Midwifery Council

16 - General Pharmaceutical Council

17 - General Osteopathic Council

18 - Social Work England
|-
|PROFESSIONAL REGISTRATION ENTRY IDENTIFIER
|The registration identifier allocated by an ORGANISATION.
|R
|
|-
|CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
|The staff group of a CARE PROFESSIONAL working in a Mental Health Service.
|R
|01 - Medical

02 - Nursing

03 - Psychology

04 - Primary Mental Health

05 - Child and Adolescent Psychotherapy

06 - Counselling

07 - Family and Systemic Psychotherapy

08 - Occupational Therapy

09 - Social Work

10 - Creative Therapy

11 - Other Therapy (Qualified)

12 - Education

13 - Speech and Language Therapy

97 - Other (Qualified)

98 - Other (Unqualified)
|-
|MAIN SPECIALTY CODE (MENTAL HEALTH)
|The Main Specialty Code of the Mental Health Responsible Clinician for the patient within the reporting period.
|R
|600 - General Medical Practice

700 - Learning Disability

710 - Adult Mental illness

711 - Child and Adolescent Psychiatry

712 - Forensic Psychiatry

713 - Medical Psychotherapy

715 - Old age psychiatry

950 - Nursing

960 - Allied Health Professional
|-
|OCCUPATION CODE
|An NHS OCCUPATION CODE for an EMPLOYEE filling a POSITION. The NHS OCCUPATION CODES are maintained by NHS Digital, on behalf of the Department of Health and can be viewed in the NHS Occupation Code Manual.
|R
|
|-
|CARE PROFESSIONAL (JOB ROLE CODE)
|A National Code for a POSITION applicable to an EMPLOYEE.
|R
|
|} 
== IAPT ==
 

=== Data Linkage ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider and may be assigned automatically by the computer system.
|M
|
|}

=== Header ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DATA SET VERSION NUMBER
|The version of the data set that this submission file is for.
|M
|
|-
|ORGANISATION IDENTIFIER (CODE OF PROVIDER)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as a Health Care Provider. This is the organisation Identifier that will be concatenated with any Local Patient Identifiers to form a unique "Local Patient Identifier" within the national database
|M
|
|-
|ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
|This is the ORGANISATION IDENTIFIER of the ORGANISATION acting as the physical sender of a Data Set submission. This Identifier provides an audit trail where a different organisation is undertaking the submission on behalf of the provider organisation.
|M
|
|-
|PRIMARY DATA COLLECTION SYSTEM IN USE
|The name of the Primary Data Collection System in use by the Health Care Provider.
|M
|
|-
|REPORTING PERIOD START DATE
|The reporting period start date to which this file refers
|M
|
|-
|REPORTING PERIOD END DATE
|The reporting period end date to which this file refers
|M
|
|-
|DATE AND TIME DATE SET CREATED
|Date/time this upload file was created
|M
|
|}

=== MPI ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|EDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The type of Educational Establishment that the student is attending.
|R
|1 - School

2 - College

3 - University

4 - Other Educational Establishment not listed

8 - Not applicable (Patient is not a student)

Z - Not stated (Patient asked but declined to provide a response)

X - Not Known (Not Recorded)
|}

=== Employment Status ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SELF EMPLOYED INDICATOR
|'An indication of whether an employed person is self-employed.
|R
|Y - Yes - Employed as a self-employed worker

N - No - Not self employed

8 - Not Applicable (Person is unemployed)

Z - Not stated (Person asked but declined to provide a response)
|-
|SICKNESS ABSENCE INDICATOR
|'An indication of whether a PERSON in EMPLOYMENT is currently unable to work due to sickness.
|R
|Y - Yes - a PERSON in EMPLOYMENT is currently unable to work due to sickness

N - No - a PERSON in EMPLOYMENT is not currently is unable to work due to sickness

8 - Not Applicable (The person is unemployed)

Z - Not stated (Person asked but declined to provide a response)

X - Not Known (Not Recorded)
|-
|STATUTORY SICK PAY RECEIPT INDICATOR
|'An indication of whether a PERSON is currently in receipt of Statutory Sick Pay, as stated by the PERSON.
|R
|Y - Yes - the person is currently in receipt of Statutory Sick Pay

N - No - the person is currently not in receipt of Statutory Sick Pay

U - Unknown (Person asked and does not know or is not sure)

Z - Not stated (Person asked but declined to provide a response)
|-
|BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|'An indication of whether a patient is currently receiving benefits, as stated by the patient.
|R
|Y - Yes - the PATIENT is currently in receipt of a benefit

N - No - the PATIENT is not currently in receipt of a benefit

U - Unknown (Person asked and does not know or is not sure)

Z - Not stated (Person asked but declined to provide a response)
|-
|EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Employment and Support Allowance, as stated by the patient.
|R
|Y - Yes - receiving Employment and Support Allowance

N - No - not receiving Employment and Support Allowance

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)
|-
|UNIVERSAL CREDIT RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Universal Credit, as stated by the patient.
|R
|Y - Yes - receiving Universal Credit

N - No - not receiving Universal Credit

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)
|-
|PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR
|'An indication of whether a patient is currently receiving Personal Independence Payment, as stated by the patient.
|R
|Y - Yes - receiving Personal Independence Payment

N - No - Not receiving Personal Independence Payment

U - Unknown (Patient asked and does not know or is not sure)

Z - Not stated (Patient asked but declined to provide a response)
|-
|EMPLOYMENT SUPPORT SUITABILITY INDICATOR
|'An indication of whether the PATIENT is a suitable candidate for referral to Employment Support.
|R
|Y - Yes - the patient is a suitable candidate for referral to Employment Support

N - No - the patient is not a suitable candidate for referral to Employment Support

N/A - Not Applicable
|-
|EMPLOYMENT SUPPORT REFERRAL DATE
|The date the PATIENT was referred for Employment Support.
|R
|
|} 

=== Social & Personal Circumstances ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE
|
|R
|
|} 
=== Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|SOURCE OF REFERRAL FOR IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES
|The source of referral to a Mental Health Service.
|R
|A1 - Primary Health Care: General Medical Practitioner Practice

A2 - Primary Health Care: Health Visitor

A3 - Other Primary Health Care

A4 - Primary Health Care: Maternity Service

B1 - Self Referral: Self

B2 - Self Referral: Carer/Relative

C1 - Local Authority and Other Public Services: Social Services

C2 - Local Authority and Other Public Services: Education Service / Educational Establishment

C3 - Local Authority and Other Public Services: Housing Service

D1 - Employer

D2 - Employer: Occupational Health

E1 - Justice System: Police

E2 - Justice System: Courts

E3 - Justice System: Probation Service

E4 - Justice System: Prison

E5 - Justice System: Court Liaison and Diversion Service

E6 - Justice System: Youth Offending Team

F1 - Child Health: School Nurse

F2 - Child Health: Hospital-based Paediatrics

F3 - Child Health: Community-based Paediatrics

G1 - Independent sector - Medium Secure Inpatients

G2 - Independent Sector - Low Secure Inpatients

G3 - Other Independent Sector Mental Health Services

G4 - Voluntary Sector

H1 - Acute Secondary Care: Emergency Care Department

H2 - Other secondary care specialty

I1 - Temporary transfer from another Mental Health NHS Trust

I2 - Permanent transfer from another Mental Health NHS Trust

M1 - Other: Asylum Services

M2 - Other: Telephone or Electronic Access Service

M3 - Other: Out of Area Agency

M4 - Other: Drug Action Team / Drug Misuse Agency

M5 - Other: Jobcentre Plus

M6 - Other SERVICE or agency

M7 - Other: Single Point of Access Service

M8 - Debt agency

N1 - Stepped up from low intensity Improving Access to Psychological Therapies Service

N2 - Stepped down from high intensity Improving Access to Psychological Therapies Service

N4 - Other Improving Access to Psychological Therapies Service

P1 - Internal Referral

Q1 - Mental Health Drop In Service
|-
|YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The year and month the PATIENT first experienced the mental health symptoms, as stated by the PATIENT.
|R
|
|-
|PREVIOUS DIAGNOSED CONDITION INDICATOR
|An indication of whether this is a recurrence of a previously diagnosed condition, as stated by a PATIENT.
|R
|Y - Yes - this is a recurrence of a previously diagnosed condition

N - No - this is not a recurrence of a previously diagnosed condition

U - Unknown (Patient asked and does not know or is unsure)

Z - Not stated (Patient asked but declined to provide a response)
|-
|DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON
|The reason that the PATIENT was discharged from an Improving Access to Psychological Therapies Service.
|R
|'''Referred but not seen'''

50 - Not assessed

'''Seen but not taken on for a course of treatment'''

10 - Not suitable for IAPT service - no action taken or directed back to referrer

11 - Not suitable for IAPT service - signposted elsewhere with mutual agreement of patient

12 - Discharged by mutual agreement following advice and support

13 - Referred to another therapy service by mutual agreement

14 - Suitable for IAPT service, but patient declined treatment that was offered

16 - Incomplete Assessment (Patient dropped out)

17 - Deceased (Seen but not taken on for a course of treatment)

95 - Not Known (Seen but not taken on for a course of treatment)

'''Seen and taken on for a course of treatment'''

46 - Mutually agreed completion of treatment

47 - Termination of treatment earlier than Care Professional planned

48 - Termination of treatment earlier than patient requested

49 - Deceased (Seen and taken on for a course of treatment)

96 - Not Known (Seen and taken on for a course of treatment)
|-
|SERVICE DISCHARGE DATE
|The date a PATIENT was discharged from a SERVICE.
|R
|
|}

=== Onward Referral ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|ONWARD REFERRAL REASON (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The reason why the patient was referred from one service to another service, which may be in the same or a different organisation.
|R
|1 - Transfer of Clinical Responsibility

2 - For Opinion Only

3 - For Diagnostic Test Only

4 - New Referral (Non Transfer)

5 - Stepped up from low intensity Improving Access to Psychological Therapies Service

6 - Stepped down from high intensity Improving Access to Psychological Therapies Service

96 - Other (not listed)

98 - Onward Referral Reason Not Applicable

99 - Not Known (Not Recorded)
|}

=== Waiting Time Pauses ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER
|The unique identifier for the period of PATIENT initiated ACTIVITY SUSPENSION.
|M
|
|-
|ACTIVITY SUSPENSION START DATE
|The date on which the break from the ACTIVITY starts.
|M
|
|-
|ACTIVITY SUSPENSION END DATE
|The date on which the break from the ACTIVITY ends.
|R
|
|-
|IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON
|The reason the PATIENT states they are unavailable for treatment for the purpose of the Improving Access to Psychological Therapies Data Set. Patient Initiated pause in the waiting period.
|R
|1 - Patient unavailable due to holiday

2 - Patient unavailable due to other health needs

3 - Patient stated not available - other reason (not listed)
|}

=== Care Contact ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|APPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR
|An indication of whether the APPOINTMENT SLOT could be reallocated, where the ATTENDED OR DID NOT ATTEND National Code is 'APPOINTMENT cancelled by, or on behalf of, the PATIENT', where the APPOINTMENT was cancelled at short notice.
|R
|Y - Yes - Appointment slot could be reallocated

N - No - Appointment slot could not be reallocated
|-
|INTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR
|An indication of whether the service providing the Improving Access to Psychological Therapies Contact was an Integrated Improving Access to Psychological Therapies Long Term Condition Service.
|M
|Y - Yes - the Improving Access to Psychological Therapies Contact was provided by an Integrated Improving Access to Psychological

Therapies Long Term Condition Service

N - No - the Improving Access to Psychological Therapies Contact was not provided by an Integrated Improving Access to Psychological

Therapies Long Term Condition Service
|-
|APPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The type of Improving Access to Psychological Therapies APPOINTMENT.
|M
|1 - Assessment

2 - Treatment

3 - Assessment and treatment

4 - Review only

5 - Review and treatment

6 - Follow-up appointment after treatment end

10 - Employment Support

98 - Other (not listed)

99 - Not Known (Not Recorded)
|-
|INTERNET ENABLED THERAPY PROGRAMME
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|R
|
|-
|NUMBER OF GROUP THERAPY PARTICIPANTS
|The number of persons who participated in the Group Therapy, excluding the Care Professionals.
|R
|
|-
|NUMBER OF GROUP THERAPY FACILITATORS
|The number of Care Professionals who facilitated the Group Therapy.
|R
|
|-
|PSYCHOTROPIC MEDICATION USAGE INDICATION CODE
|An indication of whether the PATIENT has been prescribed Psychotropic Medication and if so are they taking it, as stated by the PATIENT.
|R
|1 - Prescribed but not taking

2 - Prescribed and taking

3 - Not Prescribed

UU - Unknown (Patient asked and does not know or is not sure)

ZZ - Not stated (Patient asked but declined to provide a response)
|-
|LANGUAGE CODE (TREATMENT)
|The language used for the delivery of treatment to the Patient. LANGUAGE CODE is based on the ISO 639-1 two character language codes, see the ISO 639.2 Registration Authority website, plus five communication method extensions.
|R
|'''All Spoken Languages'''

- ISO 639-1 codes at <nowiki>http://www.loc.gov/standards/iso639-2/php/code_list.php</nowiki>

'''Extensions'''

q1 - Braille (for people who are unable to see)

q2 - American Sign Language

q3 - Australian Sign Language

q4 - British Sign Language

q5 - Makaton (devised for children and adults with a variety of communication and Learning Disabilities)
|-
|INTERPRETER PRESENT AT CARE CONTACT INDICATION CODE
|An indication of whether an interpreter was present at a Care Contact for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a Patient or Patient Proxy and if so the type of interpreter.
|R
|1 - Yes - Professional interpreter

2 - Yes - Family member or friend

3 - Yes - Another Person

4 - No - Interpreter not required

5 - No - Interpreter was required but did not attend

X - Not Known (Not Recorded)
|}

=== Internet Therapy Log ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
|The START DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
|M
|
|-
|END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
|The END DATE of the period for which the Internet Enabled Therapy Care Professional Activity Log relates to.
|M
|
|-
|INTERNET ENABLED THERAPY PROGRAMME
|The name of the Internet Enabled Therapy Programme delivered to a PATIENT.
|M
|
|-
|DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME
|The duration of clinical time in minutes spent by the IAPT Care Professional supporting Internet Enabled Therapy for the patient within the specified time period.
|M
|
|-
|INTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR
|An indication of whether an Integrated Software Engine (IAPT) was used as part of Internet Enabled Therapy.
|R
|Y - Yes - an Internet Enabled Therapy Integrated Software Engine was used as part of Internet Enabled Therapy

N - No - an Internet Enabled Therapy Integrated Software Engine was not used as part of Internet Enabled Therapy
|}

=== Medical History Previous Diagnosis ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|DIAGNOSIS DATE
|DIAGNOSIS DATE is the PERSON PROPERTY OBSERVED DATE for the PATIENT DIAGNOSIS.
|R
|
|}

=== Long Term Condition ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY)
|The CODED CLINICAL ENTRY which is used to identify a Long Term Physical Health Condition.
|M
|
|}

=== Presenting Complaints ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|PRESENTING COMPLAINT (CODED CLINICAL ENTRY)
|The CODED CLINICAL ENTRY used to identify the presenting complaint as assessed by the CARE PROFESSIONAL
|M
|
|-
|PRESENTING COMPLAINT CODING SIGNIFICANCE
|The type of the presenting complaint treated or investigated by the CARE PROFESSIONAL.
|R
|1 - Primary Presenting Complaint

2 - Secondary Presenting Complaint
|-
|PRESENTING COMPLAINT RECORDED DATE
|The date when PRESENTING COMPLAINT (CODED CLINICAL ENTRY) was recorded.
|R
|
|}

=== Care Cluster ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|END TIME (CARE CLUSTER ASSIGNMENT PERIOD)
|The time on which the assignment of a patient to a Care Cluster ended.
|R
|
|}

=== Care Personnel Qualification ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|CARE PERSONNEL LOCAL IDENTIFIER
|A unique local CARE PERSONNEL IDENTIFIER within a Health Care Provider which may be assigned automatically by the computer system.
|M
|
|-
|QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
|The qualification or individual accreditation attained or planned to be attained, by the Care Personnel.
|M
|10 - Curriculum for Psychological Wellbeing Practitioners (PWP)

11 - Curriculum for High-Intensity Cognitive Behavioural Therapy (CBT)

12 - Curriculum for Counselling for Depression (CfD)

13 - Curriculum for Couple Therapy for Depression

(CTfD) / Curriculum for Behavioural Couples

Therapy (BCT) for Depression

14 - Curriculum for Dynamic

Interpersonal Therapy (DIT) for Depression

15 - Curriculum for Practitioner Training in Interpersonal Psychotherapy (IPT)

16 - Curriculum for Mindfulness-based Cognitive Therapy (MBCT)

17 - Curriculum for Eye Movement Desensitisation Reprocessing (EMDR)

30 - Curriculum for Employment Advisers

31 - Curriculum for Senior Employment Advisers
|-
|EMPLOYEE QUALIFICATION AWARDED DATE
|The date on which a QUALIFICATION was awarded to an EMPLOYEE successfully completing a relevant EMPLOYEE TRAINING ACTIVITY or course.
|R
|
|-
|EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE
|The date on which an EMPLOYEE is expected to attain the QUALIFICATION for which they are training or studying.
|R
|
|}

=== Freeform Placeholder ===
{| class="wikitable"
!Name
!Description
!Conformance
!Codes & Primary Value Set
|-
|FREEFORM NOTES
|Any related notes deemed useful for inclusion within the DDS
|R
|
|}
__FORCETOC__