NSW Health wants to keep improving the quality of our mental health services. To achieve this, we need to perform thorough mental health assessments and reviews, document these in a standardised way and measure the effectiveness or outcomes of the care provided.
To better understand and address the needs of our consumers and to better plan their mental health care, we need to record our assessments, review and care plans in a consistent manner across the state.
These objectives have resulted in the development of the standardised mental health clinical documentation suite.
Likewise, the use of Standardised Outcome Measures has been nationally mandated under the Second National Mental Health Plan and is designed to support the assessment, monitoring and review of mental health care.
Together, the standardised mental health clinical documentation and standardised outcome measures constitute NSW Health’s Mental Health Outcomes and Assessment Tools (MH-OAT) initiative.
The aim of the initiative is to enhance the quality of clinical information available to inform mental health care by:
As a result of the initiative, clinicians have a standard way of recording the way they work with consumers and carers. This will help mental health services work more efficiently and effectively and ensure NSW meets the National Standards of Mental Health Care. MHOAT allows NSW to meet the national reporting requirements of the National Outcomes and Casemix Collection (NOCC) and the Australian Mental Health Care Classification (AMHCC), which is the mechanism for funding mental health admitted patients from 1 July 2022.
The availability of standardised clinical information in medical records facilitates communication within and between mental health services and also enables the use of such information for service development, improvement and evaluation activities.
You will be provided with a standard format (clinical modules) to document the way you work. These include standard clinical documents for triage, assessment, past history, care planning, review and discharge/transfer.
You will be expected to collect standardised measures of outcomes and casemix on admission, review and discharge/transfer of consumers.
The standard clinical documents are not scripts for a structured interview or way to approach care - they are documents for the recording, retrieval and sharing of medical record information in an accessible, standardised and structured format. The way in which assessment information is obtained from the consumer/family/other informant/s should be informed by clinical judgement to ensure that it is appropriate for the particular clinical presentation.
These clinical documents are not data collection forms - These documents will become part of the consumer’s medical record. Part of the collected information is also recorded in electronic systems to enhance access to this information for clinical purposes and for service quality improvement activities.
All the clinical documents are not used and completed at the same time - Clinical judgement is the main consideration in determining the relevant modules to be used for the particular clinical presentation.
Standardised measures are standardised tools that are used to collect routine data on outcomes of care and the casemix of consumers using a standardised protocol. There are clinician-rated measures and consumer-rated measures.
Clinician rated measures are completed at assessment, review and discharge/transfer of care. There are different measures addressing the three consumer age groups: child and adolescent (0-17 years), adult (18-64) and older persons (65+). Further information on these measures is available from the Australian Mental Health Outcomes and Classification Network.
Consumers are given the opportunity to complete a consumer self-report measure. The adult and older person consumer measure is the Kessler-10 (K10). This is a brief questionnaire that provides a global measure of psychosocial distress. The child and adolescent measure is the Strength and Difficulties Questionnaire (SDQ). This is a brief questionnaire that provides information on emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behaviour. If a consumer chooses not to complete the measure, it will not affect the treatment that they receive.
The information that is recorded in the clinical documentation becomes part of the consumer’s medical record and will be treated with the same level of confidentiality. Likewise, with the standardised outcome measures.
The collection, storage and analysis of all data collected under the MH-OAT initiative adheres to the Privacy and Personal Information Protection Act 1998.
All NSW Health mental health staff receive training from their local health district or specialty health network on the standardised clinical documentation and standardised outcome measures. However, if you have any questions, you should contact the MH-OAT Coordinator in your local health district or specialty health network. For contacts, email: InforMH@health.nsw.gov.au
Reporting Requirements of Outcome MeasuresThis Information Bulletin describes changes to the classification and code set standard for reporting of the Mental Health Outcome Assessment Tools (MHOAT) in EDWARD and the HIE.
These resources are available only for NSW Health employees via My Health Learning:
Persons using the standardised measures must abide by the terms of use specified in all licensing, copyright notices and acknowledgments relating to the individual standardised measures.
For further information, please email: InforMH@health.nsw.gov.au