Health of the Nation Outcome Scale

Health of The Nation Outcome Scale (HoNOS) rating guidelines

  • Rate items in order from 1 to 12.
  • Use all available information in making your rating.
  • Do not include information already rated in an earlier item.
  • Consider both the degree of distress the problem causes and the effect it has on behavior
  • Rate the most severe problem that occurred in the period rated.
  • The rating period is generally the preceding two weeks, except at discharge from inpatient care, when it is the previous three days.
  • Each item is rated on a five-point item of severity (0 to 4) as follows:
             0 No problem. 
             1 Minor problem requiring no formal action. 
             2 Mild problem.  
             3 Problem of moderate severity. 
             4 Severe to very severe problem. 
             9 Not known or not applicable. 
  • As far as possible, the use of rating point 9 should be avoided, because missing data make scores less comparable over time or between settings.
  • Specific information on how to rate each point on each item is provided in the Glossary.

HoNOS glossary

1. Overactive, aggressive, disruptive or agitated behaviour

Include such behaviour due to any cause, eg, drugs, alcohol, dementia, psychosis, depression, etc. Do not include bizarre behaviour, rated at Scale 6.

    0 No problems of this kind during the period rated. 
    1 Irritability, quarrels, restlessness etc.  Not requiring action. 
    2 Includes aggressive gestures, pushing or pestering others; threats or verbal  aggression; lesser damage to property (eg, broken cup or 
    window); marked over-activity or agitation. 
    3 Physically aggressive to others or animals (short of rating 4); threatening manner; more serious over-activity or destruction of 
    property. 
    4 At least one serious physical attack on others or on animals; destruction of property (e.g., fire-setting); serious intimidation or 
    obscene behaviour.  

2. Non-accidental self-injury

Do not include accidental self-injury (due eg, to dementia or severe learning disability); the cognitive problem is rated at Scale 4 and the injury at Scale 5.

Do not include illness or injury as a direct consequence of drug or alcohol use rated at Scale 3, (eg, cirrhosis of the liver or injury resulting from drunk driving are rated at Scale 5).

    0 No problem of this kind during the period rated.  
    1 Fleeting thoughts about ending it all, but little risk during the period rated; no self-harm.  
    2 Mild risk during period; includes non-hazardous self-harm eg, wrist– scratching.  
    3 Moderate to serious risk of deliberate self-harm during the period rated; includes preparatory acts eg, collecting tablets.  
    4 Serious suicidal attempt or serious deliberate self-injury during the period rated.   

3. Problem drinking or drug-taking

Do not include aggressive or destructive behaviour due to alcohol or drug use, rated at Scale 1. Do not include physical illness or disability due to alcohol or drug use, rated at Scale 5.

    0 No problem of this kind during the period rated. 
    1 Some over-indulgence, but within social norm. 
    2 Loss of control of drinking or drug-taking; but not seriously addicted. 
    3 Marked craving or dependence on alcohol or drugs with frequent loss of control, risk taking under the influence, etc. 
    4 Incapacitated by alcohol or drug problems.  
    

4. Cognitive problems

Include problems of memory, orientation and understanding associated with any disorder: learning disability, dementia, schizophrenia, etc. Do not include temporary problems (eg, hangovers) resulting from drug or alcohol use, rated at Scale 3.

    0 No problem of this kind during the period rated. 
    1 Minor problems with memory or understanding eg, forgets names occasionally. 
    2 Mild but definite problems, eg, has lost way in a familiar place or failed to recognise a familiar person; sometimes mixed up about 
    simple decisions. 
    3 Marked disorientation in time, place or person, bewildered by everyday events; speech is sometimes incoherent, mental slowing. 
    4 Severe disorientation, eg, unable to recognise relatives, at risk of accidents, speech incomprehensible, clouding or stupor. 

5. Physical illness or disability problems

Include illness or disability from any cause that limits or prevents movement, or impairs sight or hearing, or otherwise interferes with personal functioning. Include side-effects from medication; effects of drug/alcohol use; physical disabilities resulting from accidents or self-harm associated with cognitive problems, drunk driving etc. Do not include mental or behavioural problems rated at Scale 4.

    0 No physical health problem during the period rated. 
    1 Minor health problem during the period (eg, cold, non-serious fall, etc). 
    2 Physical health problem imposes mild restriction on mobility and activity. 
    3 Moderate degree of restriction on activity due to physical health problem. 
    4 Severe or complete incapacity due to physical health problem.
 

6. Problems associated with hallucinations and delusions

Include hallucinations and delusions irrespective of diagnosis. Include odd and bizarre behaviour associated with hallucinations or delusions. Do not include aggressive, destructive or overactive behaviours attributed to hallucinations or delusions, rated at Scale 1.

     0 No evidence of hallucinations or delusions during the period rated. 
     1 Somewhat odd or eccentric beliefs not in keeping with cultural norms. 
     2 Delusions or hallucinations (eg, voices, visions) are present, but there is little distress to patient or manifestation in bizarre 
    behaviour, that is, moderately severe clinical problem. 
     3 Marked preoccupation with delusions or hallucinations, causing much distress and/or manifested in obviously bizarre behaviour, 
    that is, moderately severe clinical problem. 
     4 Mental state and behaviour is seriously and adversely affected by delusions or hallucinations, with severe impact on patient.  

7. Problems with depressed mood

Do not include over-activity or agitation, rated at Scale 1. Do not include suicidal ideation or attempts, rated at Scale 2. Do not include delusions or hallucinations, rated at Scale 6.

     0 No problems associated with depressed mood during the period rated. 
     1 Gloomy; or minor changes in mood. 
     2 Mild but definite depression and distress: eg, feelings of guilt; loss of selfesteem. 
     3 Depression with inappropriate self-blame, preoccupied with feelings of guilt. 
     4 Severe or very severe depression, with guilt or self-accusation.  

8. Other mental and behavioural problems

Rate only the most severe clinical problem not considered at items 6 and 7 as follows: specify the type of problem by entering the appropriate letter: A phobic: B anxiety; C obsessive-compulsive; D stress; E dissociative; F somatoform; G eating; H sleep; I sexual; J other, specify.

     0 No evidence of any of these problems during period rated. 
     1 Minor non-clinical problems. 
     2 A problem is clinically present at a mild level, eg, patient/client has a degree of control. 
     3 Occasional severe attack or distress, with loss of control eg, has to avoid anxiety provoking situations altogether, call in a neighbour to help, etc., that is, a moderately severe level of problem. 4 Severe problem dominates most activities. 

9. Problems with relationships

Rate the patient’s most severe problem associated with active or passive withdrawal from social relationships, and/or non-supportive, destructive or selfdamaging relationships.

     0 No significant problems during the period. 
     1 Minor non-clinical problems. 
     2 Definite problems in making or sustaining supportive relationships: patient complains and/or problems are evident to others. 
     3 Persisting major problems due to active or passive withdrawal from social relationships, and/or to relationships that provide little 
     or no comfort or support. 
    4 Severe and distressing social isolation due to inability to communicate socially and/or withdrawal from social relationships.  

10. Problems with activities of daily living

Rate the overall level of functioning in activities of daily living (ADL): eg, problems with basic activities of self-care such as eating, washing, dressing, toilet; also complex skills such as budgeting, organising where to live, occupation and recreation, mobility and use of transport, shopping, self-development, etc. Include any lack of motivation for using self-help opportunities, since this contributes to a lower overall level of functioning. Do not include lack of opportunities for exercising intact abilities and skills, rated at Scale 11 and Scale 12.

    0 No problems during period rated; good ability to function in all areas. 
    1 Minor problems only eg, untidy, disorganised. 
    2 Self-care adequate, but major lack of performance of one or more complex skills (see above). 
    3 Major problems in one or more areas of self-care (eating, washing, dressing, toilet) as well as major inability to perform several 
    complex skills. 
    4 Severe disability or incapacity in all or nearly all areas of self-care and complex skills. 

11. Problems with living conditions

Rate the overall severity of problems with the quality of living conditions and daily domestic routine. Are the basic necessities met (heat, light, hygiene)? If so, is there help to cope with disabilities and a choice of opportunities to use skills and develop new ones? Do not rate the level of functional disability itself, rated at Scale 10. NB: Rate patient’s usual accommodation. If in acute ward, rate the home accommodation. If information not obtainable, rate 9.

    0 Accommodation and living conditions are acceptable; helpful in keeping any disability rated at Scale 10 to the lowest level possible, 
    and supportive of self-help. 
    1 Accommodation is reasonably acceptable although there are minor or transient problems (eg, not ideal location, not preferred option, 
    doesn’t like food, etc). 
    2 Significant problems with one or more aspects of the accommodation and/or regime (eg, restricted choice; staff or household have 
    little understanding of how to limit disability, or how to help develop new or intact skills). 
    3 Distressing multiple problems with accommodation (eg, some basic necessities absent); housing environment has minimal or no 
    facilities to improve patient’s independence. 
    4 Accommodation is unacceptable (eg, lack of basic necessities, patient is at risk of eviction, or ‘roofless’, or living conditions are 
    otherwise intolerable making patient’s problems worse). 

12. Problems with occupation and activities

Rate the overall level of problems with quality of day–time environment. Is there help to cope with disabilities, and opportunities for maintaining or improving occupational and recreational skills and activities? Consider factors such as stigma, lack of qualified staff, access to supportive facilities, eg, staffing and equipment of day centres, workshops, social clubs, etc. Do not rate the level of functional disability itself, rated at Scale 10. NB: Rate the patient’s usual situation. If in acute ward, rate activities during period before admission. If information not available, rate 9.

    0 Patient’s day–time environment is acceptable; helpful in keeping any disability rated at Scale 10 to the lowest level possible, and 
    supportive of self-help. 
    1 Minor or temporary problems, eg, late pension cheques, reasonable facilities available but not always at desired times etc. 
    2 Limited choice of activities, eg, there is a lack of reasonable tolerance (eg, unfairly refused entry to public library or baths etc.); or 
    handicapped by lack of a permanent address; or insufficient carer or professional support; or helpful day setting available but for 
    very limited hours. 
    3 Marked deficiency in skilled services available to help minimise level of existing disability; no opportunities to use intact skills or 
    add new ones; unskilled care difficult to access. 
    4 Lack of any opportunity for daytime activities makes patient’s problem worse.