State-wide Standardised Clinical Documentation for Mental Health Services

Applicable to: Health Service Providers providing mental health services.

Description: This Policy mandates the use of Statewide Standardised Clinical Documentation for all Western Australian public mental health services to document clinical care.

Statewide Standardised Clinical Documentation facilitates standardised recording, retrieval and sharing of medical record information at all points of care for the consumer, from triage through to discharge, with the primary goal of improving mental health consumer health outcomes by enhancing the clinical information available to inform care decisions. Statewide Standardised Clinical Documentation incorporates a range of tools for public mental health services to record information required under the Mental Health Act 2014, the Chief Psychiatrist’s Standards for Clinical Care and National Standards for Mental Health Services 2010. The Policy additionally aims to address recommendations from the Review of admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia.

This Policy is a mandatory requirement under the Mental Health Policy Framework pursuant to section 26(2)(c) of the Health Services Act 2016.

This Policy supersedes OD: 0526/14 Statewide Standardised Clinical Documentation (SSCD) for Mental Health Services.

Date of effect: 17 March 2021

Policy Framework

Related documents

Supporting information