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:

  • introducing uniform clinical information collection protocols
  • implementing standard clinical documentation (clinical modules) designed to support the recording and retrieval of information at different points in the cycle of mental health care
  • implementing the routine collection of outcomes and casemix measures.

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. 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.

On this page

What MH-OAT means for you?

You will be provided with a standard format (clinical modules) to document the way you work. These include standard clinical modules for triage, assessment; care planning, review and discharge.

You will be expected to collect standardised measures of outcomes and casemix on admission; review and discharge of consumers (see MH-OAT Data Collection Reporting Requirement).

What the initiative is not

The clinical modules used to record your assessments are not scripts for a structured interview - The assessment modules are forms for documenting collected information in a standardised 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 modules are not data collection forms - These modules 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 modules 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.

What are standardised outcome measures?

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

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.

Consumer-rated measures

Consumers are given the opportunity to complete a consumer self-report measure. The adult and older person consumer measure is the Kessler-10 (K10) and the child and adolescent measure is the Strength and Difficulties Questionnaire (SDQ). The K10 provides information on how the consumer has been feeling recently. The SDQ provides information on how an adolescent consumer has been feeling and doing recently. If a consumer chooses not to complete the measure, it will not affect the treatment that they receive.

Who will this information be made available to?

The information that is recorded in the clinical documentation modules 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 adhere to the Privacy and Personal Information Protection Act 1998.

What if I have other questions or concerns?

All NSW Health mental health staff receive training from their local health district 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 email the NSW Project Manager MH-OAT.

Policy directives

  • Mental Health Clinical Documentation
    This Policy Directive relates to the mandatory requirement to use standardised clinical documentation within NSW public mental health services.
  • MH-OAT Data Collection Reporting Requirement
    This Policy Directive relates to the mandatory requirement to collect standardised outcome measures and casemix information within NSW public mental health services.
  • Information Bulletin on the Redesigned Mental Health Clinical Documentation
    The purpose of this Information Bulletin is to notify mental health staff of the availability of redesigned mental health clinical documentation. The modules were redesigned in response to the comprehensive evaluation undertaken during 2006/07, with the redesign overseen and approved by NSW Health's Mental Health Program Council.

Resources

Child and Adolescent Facilitator’s Manual
An educational resource for the delivery of training on the use of the mental health clinical documentation and routine outcome measures to clinical staff working with children and adolescents. This document is currently undergoing review to reflect the redesigned Mental Health Clinical Documentation.

Useful links

Australian Mental Health Outcomes and Classification Network (AMHOCN)
Information on routine outcomes and case complexity measurement in Australian mental health services.

Copyright notices

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.

Further information

For further information, please email the NSW Project Manager MH-OAT.

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Page Updated: Friday 14 December 2018
Contact page owner: Mental Health Branch