IAPT Documentation and Outcome Measures (UK)

What Is IAPT Documentation?

IAPT (Improving Access to Psychological Therapies) — now rebranded as NHS Talking Therapies — is the NHS programme that provides evidence-based psychological treatment for common mental health conditions, primarily depression and anxiety disorders. IAPT documentation refers to the specific clinical recording, outcome monitoring, and data reporting requirements that apply within this programme.

IAPT is distinctive in its commitment to routine outcome monitoring. Unlike most mental health services, where outcome measures are collected at assessment and discharge (if at all), IAPT requires validated outcome measures at every treatment session. This session-by-session monitoring generates a clinical trajectory that informs treatment decisions in real time and feeds into national performance data that determines service funding and evaluation.

The IAPT minimum data set (MDS) defines the specific data points that must be collected and submitted to NHS Digital for every patient who enters the service. This includes demographic information, referral source, waiting times, assessment and treatment dates, outcome measure scores at every contact, treatment modality, session counts, and discharge outcomes. The quality and completeness of this data directly affects the service's reported performance — and therefore its funding and reputation.

For psychologists and psychological therapists working in IAPT services, understanding the documentation requirements is not optional. The data you collect at every session is not bureaucratic overhead — it is a fundamental component of the clinical model.

When You Need It

You create IAPT documentation at every stage of the patient pathway:

• Referral and assessment — documenting the referral source, initial assessment, triage decision, and step allocation
• Every treatment session — recording outcome measures (PHQ-9, GAD-7, and disorder-specific measures), session content, and clinical observations
• Stepping decisions — documenting clinical rationale when stepping a patient up (from Step 2 to Step 3), stepping down, or referring out of the service
• Discharge — completing discharge documentation including final outcome measures, discharge reason, and referral to other services if applicable
• Did Not Attend (DNA) management — documenting non-attendance, attempts to re-engage, and decisions about discharge following non-attendance
• Supervision — documenting supervision discussions, case formulations, and treatment decisions (kept in supervision records, not patient records)

Key Components / Requirements

Minimum Data Set (MDS)

The IAPT minimum data set defines the mandatory data collected for every patient. Key elements include:

• Demographics: Age, gender, ethnicity, employment status, disability status, and postcode (for deprivation indices)
• Referral information: Source of referral (GP, self-referral, other), date of referral, date of first contact
• Waiting times: Days between referral and first assessment, days between assessment and first treatment session (national target: first treatment within 6 weeks for 75% of patients, within 18 weeks for 95%)
• Outcome measures: PHQ-9 and GAD-7 scores at every clinical contact, plus disorder-specific measures where relevant
• Treatment information: Treatment modality (guided self-help, computerised CBT, group psychoeducation, individual CBT, counselling, EMDR, IPT, couples therapy, etc.), number of sessions attended, step level
• Discharge information: Discharge date, reason for discharge (completed treatment, dropped out, referred on, etc.), final outcome measure scores

Outcome Measures — Session by Session

The following measures are collected at every treatment session:

PHQ-9 (Patient Health Questionnaire-9): A 9-item self-report measure of depression severity. Scores range from 0 to 27. Clinical threshold: 10. Reliable change: 6 points.

GAD-7 (Generalised Anxiety Disorder-7): A 7-item self-report measure of anxiety severity. Scores range from 0 to 21. Clinical threshold: 8. Reliable change: 4 points.

WSAS (Work and Social Adjustment Scale): A 5-item measure of functional impairment. Scores range from 0 to 40. Often collected at assessment and discharge rather than every session.

Disorder-specific measures (collected where the primary problem is a specific anxiety disorder or PTSD):

• PCL-5 for PTSD
• OCI-R for OCD
• SPIN for social anxiety disorder
• Mobility Inventory or PDA for panic disorder with agoraphobia
• GAD-7 also serves as the primary measure for generalised anxiety disorder
• PHQ-9 also serves as the primary measure for depression

Stepped Care Documentation

IAPT operates on a stepped care model:

Step 1: Assessment and signposting (not a treatment step within IAPT) Step 2: Low-intensity interventions — guided self-help, computerised CBT, group psychoeducation, delivered by Psychological Wellbeing Practitioners (PWPs) Step 3: High-intensity interventions — individual CBT, EMDR, IPT, counselling for depression, couples therapy, delivered by High Intensity Therapists (HITs), clinical psychologists, or counselling psychologists

Document the step allocation at assessment and the clinical rationale for any stepping decisions. When stepping a patient up from Step 2 to Step 3, document why the low-intensity intervention was insufficient and what high-intensity treatment is recommended.

Clinical Session Records

Beyond the outcome measure scores, each session should be documented with a concise clinical note that includes the session focus, interventions used, homework assigned and reviewed, and any risk issues. The level of detail is typically less than a full NHS clinical psychology note — IAPT session records are designed to be efficient, data-driven, and focused on demonstrating that evidence-based treatment is being delivered with fidelity.

How to Write It

Step 1: Collect outcome measures before the session begins. Many services have patients complete the PHQ-9 and GAD-7 in the waiting room or online before the session. This allows you to review the scores at the start of the session and use them clinically — discussing changes, exploring discrepancies between scores and presentation, and adjusting the session plan accordingly.

Step 2: Use the scores clinically, not just administratively. Session-by-session outcome monitoring is a clinical tool, not just a data collection requirement. If the GAD-7 has increased by 5 points since last session, explore why. If the PHQ-9 has not moved in 4 sessions, discuss this with the patient and review the treatment approach. Document these clinical discussions.

Step 3: Record the clinical trajectory. In your session record, note not just the current scores but the trajectory — is the patient improving, stable, or deteriorating? How do current scores compare to assessment scores? This trajectory information informs stepping decisions and is useful for supervision.

Step 4: Document homework clearly. IAPT treatments are homework-intensive. Document what homework was assigned at the end of each session and whether the previous session's homework was completed at the start of the next session. Homework completion is a strong predictor of outcomes and should be tracked.

Step 5: Enter data promptly. IAPT data submission deadlines are strict. Enter your outcome measure scores and session data into the service's data system on the day of the session or as soon as possible thereafter. Late or missing data affects the service's reported performance metrics.

Step 6: Document stepping decisions with clinical rationale. When you decide to step a patient up (from Step 2 to Step 3), step them down, or refer them out of the service, document the clinical rationale. This should reference the outcome data, the clinical formulation, and the evidence base for the recommended next step.

How to Write It (continued)

Step 7: Complete discharge documentation thoroughly. At discharge, ensure that final outcome measures are collected and recorded. Calculate whether the patient achieved reliable recovery (moved below clinical thresholds with reliable change), reliable improvement (reliable change without moving below thresholds), no reliable change, or reliable deterioration. Document the discharge reason and any onward referrals.

Common Mistakes

• Not collecting outcome measures at every session. This is the most fundamental IAPT requirement. Missing data points disrupt the clinical trajectory, affect service performance metrics, and undermine the clinical model. If a patient refuses to complete measures, document this and explore the reasons.
• Collecting measures but not using them clinically. If you collect the PHQ-9 and GAD-7 but never discuss the scores with the patient or use them to inform treatment decisions, you are missing the clinical purpose of routine outcome monitoring. The scores should inform the session, not just the database.
• Continuing treatment unchanged when outcome data shows no improvement. The IAPT model expects therapists to respond to outcome data. If scores are static or worsening after 4 to 6 sessions, the treatment approach should be reviewed — through supervision, formulation review, or stepping decisions.
• Poor documentation of stepping decisions. Moving a patient from Step 2 to Step 3 (or referring out of the service) without documenting the clinical rationale creates governance gaps. Document why the current step is insufficient and what the recommended next step offers.
• Failing to distinguish between DNA, cancellation, and unplanned ending. IAPT services report on different types of discharge. A patient who does not attend and cannot be re-engaged is different from one who completes treatment. Accurate categorisation affects service performance data.
• Not recording the treatment modality accurately. IAPT reports on which evidence-based treatments are being delivered. If you are providing CBT, record it as CBT — not as "counselling" or "therapy." Accurate modality coding supports service evaluation and NICE concordance reporting.