Recording autism and ADHD assessments in Mental Health Services Data set (MHSDS)

Referral

When it becomes clear that a referral for autism assessment is required then please record 'Suspected Autism' as the primary reason for referral in clinical system, along with the date the referral was made. 

In MHSDS this means:

Please ensure all prior referrals in the pathway are recorded appropriately, that is, referrals to MDT teams or Mental Health Services. 

Assessment 

If the assessment is attended then update the care contact field to reflect this and the method of assessment, then add a care activity to indicate an autism assessment using SNOMED code '1085671000000109'. 

You should also record the date of the assessment. 

In MHSDS this means:

Note: If the assessment takes place over multiple sessions or dates, please record each individual assessment as above. 

Diagnosis

If diagnosis of autism is confirmed, record autism as primary diagnosis and ensure the date of the diagnosis is recorded.

Note: The date should reflect when the diagnosis was given to the patient NOT when it is recorded in the system.

In MHSDS if using SNOMED this means:

For a list of the most common SNOMED codes used for autism see appendix 1.

It is preferable to submit data using SNOMED codes, however if providers wish to submit a diagnosis of autism using ICD-10 codes this can be done using the following:

Further care contacts and activity

Record any other relevant care by updating care contact and care activity as required. For example, if a medication review is carried out, record medication review using the appropriate SNOMED code '1099461000000101'. A telephone call being made to the patient can be recorded within the care contact table. These are just examples of care contacts and activity that could be recorded – providers should continue to record additional care activity as has been done previously. 

For example:

 

Please note that further care contacts and activity can be recorded at any point in the process between referral and discharge. 

Discharge

After assessment, diagnosis (or not being diagnosed) and all additional care contacts and activity, then record the discharge from the service when appropriate to do so. Discharge may not happen for some time after the assessment for multiple reasons.

In MHSDS this means:

Referral

When it becomes clear that a referral for ADHD is required, record 'Neurodevelopmental Conditions, excluding Autism' as primary reason for referral in clinical system and add 'Suspected ADHD' as a presenting complaint. 

In MHSDS this means:

Please ensure all prior referrals in the pathway are recorded appropriately, that is, referrals to MDT teams or Mental Health Services. 

Assessment

If the assessment is attended then update the care contact field to reflect this and the method of assessment. Then add a care activity to indicate an ADHD assessment using SNOMED code '1914891000000100'.

You should also record the date of the assessment. 

In MHSDS this means:

Note: If the assessment takes place over multiple sessions or dates, please record each individual assessment as above. 

Diagnosis

If diagnosis of ADHD is confirmed then record ADHD as primary diagnosis and ensure the date of the diagnosis is recorded.

Note: The date should reflect when the diagnosis was given to the patient NOT when it is recorded in the system.

In MHSDS this means:

For a list of the most common SNOMED codes used for ADHD see appendix 1.

It is preferable to submit data using SNOMED codes, however if providers wish to submit a diagnosis of ADHD using ICD-10 codes this can be done using the following:

Further care contacts and activity

Record any other relevant care by updating care contact and care activity as required. For example, if a medication review is carried out record medication review using the appropriate SNOMED code '1099461000000101'. A telephone call being made to the patient can be recorded within the care contact table. These are just examples of care contacts and activity that could be recorded – providers should continue to record additional care activity as has been done previously.

For example:

 

Please note that further care contacts and activity can be recorded at any point in the process between referral and discharge. 

Discharge

After assessment, diagnosis (or not being diagnosed) and all additional care contacts and activity, then record the discharge from the service when appropriate to do so. Discharge may not happen for some time after the assessment for multiple reasons.

Referral

When it becomes apparent there is a need for both an autism and ADHD assessment to be carried out please record 'Suspected Autism' as primary reason for referral in clinical system AND 'Neurodevelopmental Conditions, excluding Autism' as the other reason for referral, AND add 'Suspected ADHD' and 'Suspected Autism' as presenting complaints.

In MHSDS this means:

Note: The referring clinician may decide it is more appropriate to class ADHD as the primary reason for referral. If so then record 'Neurodevelopmental Conditions, excluding Autism' as the primary reason for referral in clinical system AND record 'Suspected Autism' as the other reason for referral, AND add 'Suspected ADHD' and 'Suspected Autism' as presenting complaints.

Please ensure all prior referrals in the pathway are recorded appropriately, that is, referrals to MDT teams or Mental Health Services. 

Assessment 

If the autism assessment is attended then update the care contact field to reflect this and the method of assessment, then add a care activity to indicate an autism assessment using SNOMED code '1085671000000109'.

You should also record the date of the assessment. 

In MHSDS this means: 

If the ADHD assessment is attended then update the care contact field to reflect this and the method of assessment, then and add a care activity to indicate an ADHD assessment using SNOMED code '1914891000000100'.

You should also record the date of the assessment. 

In MHSDS this means:

Note: If either assessment takes place over multiple sessions or dates, please record each individual assessment as above.

Diagnosis

If a diagnosis is made for only one condition then follow autism or ADHD specific guidance.

If diagnosed with both autism and ADHD then record:

• autism as the primary diagnosis 
• ADHD as a secondary diagnosis

Ensure the diagnosis date is recorded.

Note: The date should reflect when the diagnosis was given to the patient NOT when it is recorded in the system.

In MHSDS this means:

For a list of the most common SNOMED codes used for autism and ADHD see appendix 1.

The clinician may decide it is more appropriate to record ADHD as the primary diagnosis and autism as the secondary diagnosis, in which case the following would need to be recorded in MHSDS:

It is preferable to submit data using SNOMED codes, however if providers wish to submit a diagnosis of autism using ICD-10 codes this can be done using the following:

If providers wish to submit a diagnosis of ADHD using ICD-10 codes, this can be done using the following:

Autism SNOMED codes

Full list of all SNOMED codes relating to autism.

The most commonly used codes:

35919005 - Pervasive developmental disorder (disorder)
408856003 - Autistic disorder (disorder)
23560001 - Asperger's disorder (disorder)

ADHD SNOMED codes

Full list of all SNOMED codes relating to ADHD.

The most commonly used codes:

406506008 - Attention deficit hyperactivity disorder (disorder)