MH-03

Core Requirement

Published

V3.0 - March 2023

MH-03.1 - Recording Therapeutic Observations

DCF Core Capability

As a mental health professional,

I want to record therapeutic observations in an inpatient mental health setting,

So that a patient's progress can be recorded and reviewed

Acceptance criteria 1:

Given a user has the correct permissions,

When carrying out patient observation,

Then therapeutic observations can be recorded on the patient care plan.

Application Function

Description

AF389 Record Therapeutic intervention

Enable recording of therapeutic observations against the patient record

Standards Compliance

• STD004 AIDC: Automatic Identification and Data Capture - ISB 0108 Guidance

• STD013 Child Protection Information Sharing - DCB1609 Guidance (NHS Digital)

• STD030 Digital Imaging and Communications in Medicine (DICOM) - ISB 1556 Guidance

• STD039 Health and Social Care Organisation Reference Data - DCB0090 Guidance (NHS Digital)

• STD043 Identity Verification and Authentication Standard for Digital Health and Care Services - DCB3051 Guidance (NHS Digital)

• STD045 Data Security and Protection Toolkit - Data Security and Protection Toolkit

• STD080 UK Edition SNOMED CT - SCCI0034 Guidance (NHS Digital)

• STD097 Outpatient letter – Outpatient letter – PRSB

• STD116 Personalised Care and Support Plan -

• Personalised Care and Support Plan

• STD117 Care homes view of shared care records -

• Care homes view of shared care records

DCF Transformation Capability

As a mental health Professional,

I want to record therapeutic observations for inpatient mental health setting on a mobile device,

So that care can be recorded on a wider range of devices.

Acceptance criteria 1:

Given the system is online and accessible,

When the system is viewed on a mobile device,

Then the system should have the same functionality as it does on desktop devices.

Application Function

Description

AF389 Record Therapeutic intervention

Enable recording of therapeutic observations against the patient record

AF326 Maintain Patient Record via Mobile App

The ability for a user to view/update a Patient medical record via a Mobile Device

Standards Compliance

• STD004 AIDC: Automatic Identification and Data Capture - ISB 0108 Guidance

• STD013 Child Protection Information Sharing - DCB1609 Guidance (NHS Digital)

• STD030 Digital Imaging and Communications in Medicine (DICOM) - ISB 1556 Guidance

• STD039 Health and Social Care Organisation Reference Data - DCB0090 Guidance (NHS Digital)

• STD043 Identity Verification and Authentication Standard for Digital Health and Care Services - DCB3051 Guidance (NHS Digital)

• STD045 Data Security and Protection Toolkit - Data Security and Protection Toolkit

• STD080 UK Edition SNOMED CT - SCCI0034 Guidance (NHS Digital)

• STD097 Outpatient letter – Outpatient letter – PRSB

• STD116 Personalised Care and Support Plan -

• Personalised Care and Support Plan

• STD117 Care homes view of shared care records -

• Care homes view of shared care records

The following standards are applicable to the secondary care setting:

• Mental Health Standards List

⬅️ Care Plans

Requirements Map

Mental Health Medicine Management ➡️