ID | MH-03 |
|---|---|
Type | Core Requirement |
Status | Published |
Release | V3.0 - March 2023 |
MH-03 Recording of therapeutic observations
Electronic recording of therapeutic observations in inpatient mental health settings.
Electronic recording of therapeutic observations in inpatient mental health settings via mobile devices
Core Level Requirements
Transformation & Innovation Level Requirements
Description
Inpatient mental health care relies on ‘Therapeutic Observations’ to be routinely completed by staff. Staff make qualitative observations of a patient’s mental state and behaviour at predetermined regular intervals, or even continuously, such that it may prompt them to make an intervention to provide additional support to reduce distress, anxiety or low mood. These user stories describe the need to record these types of therapies in the patient record.
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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) | |
| Data Security and Protection Toolkit - | |
| - SCCI0034 Guidance (NHS Digital) | |
| – Outpatient letter – PRSB | |
| Personalised Care and Support Plan - | |
STD117 Care homes view of shared care records - Care homes view of shared care records | |
MH-03.2 - Mobile Access | |
|---|---|
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 | |
| - SCCI0034 Guidance (NHS Digital) | |
| – Outpatient letter – PRSB | |
STD116 Personalised Care and Support Plan - Personalised Care and Support Plan | |
| Care homes view of shared care records - | |
Applicable Standards |
|---|
The following standards are applicable to the secondary care setting: |
⬅️ Care Plans | Requirements Map | Mental Health Medicine Management ➡️ |
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