Clinical coding is the translation of terminology used in healthcare into a coded form.
It involves standardisation of terms, and the placing of codes in a structured hierarchy.
Clinical terminologies are comprehensive lists of terms used in the care, treatment and management of patients, which enable computer systems to store, and retrieve patient information in a natural clinical language.
There are different types of clinical terminologies for different purposes eg:
To create an electronic patient record
To manage a payment system in the private sector ICD9CM
Clinical terminologies used for this purpose have a multitude of functions. These include:
Allowing the development of a computer system that uses clinical data
Creating a standard language for use in healthcare computer systems
Enabling decision support to be performed by computer systems, e.g. PRODIGY/Scriptswitch which allow an EPR to be searched to see whether a particular drug is suitable for a specific patient, given his/her medical history
Enabling clinical management based on collated patient data, i.e. clinical audit
Clinical terminologies support structured clinical information, which in turn can be searched or reported via the computer.
ICD 10 International disease classifications for epidemiological purposes now more widely mandated for billing etc
OPCS4 operations, procedures and interventions
Comprehensive list of clinical terms intended for use by healthcare professionals to describe the care and treatment given to patients.
They include signs, symptoms, treatments, investigations, occupations, diagnoses and drugs and appliances.
Invented and developed in 1982 by a GP, Dr James Read initially used only Read Codes were only used in general practice, but they have been significantly developed and improved over the years and are now used throughout the NHS and indeed were purchased by NHS in 1990.
The Read system has a hierarchical structure comprising five levels of detail.
Each successive level provides more detail to a concept.
The top level of the hierarchy is known as the chapter.
Hierarchical 5 byte case-sensitive alphanumerical – each level describing the term in greater detail. If the code being used is from one of the higher levels in the hierarchy, i.e. less detailed, the remainder of the 5 bytes are padded with dots
G…. Circulatory system diseases
G3… Ischaemic heart disease
G30.. Acute myocardial infarction
G301. Anterior myocardial infarction NOS
G3011 Acute anteroseptal infarction
Each code has one preferred term to describe it in words, such as `Acute anteroseptal infarction’ above, and may have any number of synonymous terms, such as `heart attack’.
& includes the code itself plus all the heirarchical childrens codes
– includes the listed codes plus all the codes in between
1 is number 1
0 is the number zero
l is lower case letter L
I is upper case I
The chapters are divided into three areas:
Chapters that start with a number (0 to 9), refer to a process of medicine.
Chapters that start with a capital letter (A to Z), refer to diagnoses.
Chapters that start with a lower case letter (a – y) refer to medication and appliances.
1. Process Of Medicine
3 Diagnostic procedures
4 Laboratory procedures
5 Radiology/physics in medicine
6 Preventative procedures
7 Operations, procedures, sites
8 Other therapeutic procedures
A Infectious/parasitic diseases
C Endocr/nutr/metabolic/immun. diseases
D Blood/blood forming organs diseases
E Mental disorders
F Nervous system/sense organ diseases
G Circulatory system diseases
H Respiratory system disorders
J Digestive system disorders
K Genitourinary system diseases
M Skin/subcutaneous tissue diseases
N Musculoskeletal/connective tissue
P Congenital anomalies
Q Perinatal conditions
[D] Symptoms, signs, ill-defined conditions
S Injury and self poisoning
T Causes of injury/poisoning
[X] External causes morbidity/mortality
Z Unspecified conditions
Read Code Guide (PRIMIS)
Read codes are a coded thesaurus of clinical terms used to record data on clinical computer systems.
The Read codes are designed to cover almost anything which clinicians may wish to record on their clinical system. Topics covered include occupations, signs and
symptoms, investigations, diagnoses, operations, drugs, therapies, and general administrative information.
Read codes are cross-mapped to ICD9/ICD-10 (for diseases), OPCS-4 (for operations, procedures and interventions), BNF and ATC (for drugs).
Information can be entered onto clinical systems in a number of different formats.
? Free text Practice staff can enter information as text. Information entered in this way is very difficult to retrieve.
Codes represent an efficient and consistent method of storing and retrieving clinical information, enabling practices to conduct searches and facilitating clinical audit.
The usage of Read codes is mandatory in GP clinical systems. Hence they represent a national standard, enhancing consistency in, and facilitating the communication of, clinical records.
There are two versions of Read codes, which are used by clinical systems in general practice. They are: 4-byte (version 0) & 5-byte (version 2) If you are unsure which version of the Read codes your systems uses, please contact your system supplier.
8 What does 4-byte and 5-byte mean?
This refers to the number of alphanumeric characters allowed for each code. A 4-byte Read code must be 4 characters long and a 5-byte Read code must be 5 characters long. The codes are not interchangeable. You will often see Read
codes written as H43 (4-byte read code) or H33 (5-byte read code). When these codes are entered onto the clinical computing system they must be made
up to correct number of characters by using dots.
4-byte read code H43 H43.
5-byte read code H33 H33..
9 Read codes and ‘+’ Symbol
You will often see a Read code followed by a ‘+’ symbol e.g. H43+ or H33+. The ‘+’ symbol cannot be entered onto the computer system. The ‘+’ symbol is used to
indicate that there are more codes available in the underlying hierarchical structure which practice staff can use if they want to record 0 more detailedclinical information about this concept.
10 How do Read Codes Work?
They are a representation of the information required to enable clinicians to monitor and manage patients in general practice. Each piece of information or
‘concept’ has a preferred ‘term’, one or more synonymous terms, and a unique alphanumeric code (Read code).
Read code – G30..
Term Acute Myocardial Infarction
Preferred Synonyms Heart Attack, Acute MI, MI
Although information is recorded in the clinical system as a read code whenever the user displays the information they will only see the attached clinical term.
This makes the stored information more meaningful, and frees the user from having to remember the underlying codes.
11 Read Code Hierarchy
Read Codes are arranged into an hierarchy describes which concepts are types
of something else. For example:
Myocardial infarction is a type of Ischaemic Heart Disease which is a type of
Heart Disorder which is a type of Cardiovascular disorder which is a type of
Clinical finding (diagnosis)
The hierarchical structure is indicated in the digits of the code itself from left
to right. e.g.
Circulatory disorders G….
Hypertensive disease G2…
Essential hypertension G20..
Malignant essential hypertension G200.
The hierarchical structure has the advantage that the code can be entered at a level of detail dependant upon:
?the level of clinical information available i.e. a GP may only be informed that a patient has had an acute myocardial infarction
?the GP’s clinical judgement
?the specific reason for collecting the data i.e. administration, clinical management, audit or governance
|Read code chapters
Processes of care (0-9)
|1 History & symptoms|
|2 Examinations & signs|
|3 Diagnostic procedures|
|4 Laboratory procedures|
|6 Preventative procedures|
|7 Operative procedures|
|8 Other therapeutic procedure|
|Diagnoses (A-Z uppercase)|
|C Endocrine, nutrition & metabolic diseases|
|D Blood & blood forming organs|
|E Mental & behavioural disease|
|F Nervous system and sense organs|
|i Nutrition and blood|
|J Digestive system diseases (I)|
|K Genitourinary system dis. (J)|
|L Pregnancy, childbirth etc (K)|
|M Skin & subcutaneous tissue. (L)|
|N Musculoskeletal & connective tissue diseases (M)|
|P Congenital anomalies (N)|
|Q Perinatal conditions (O)|
|R Symptoms, signs and ill-defined conditions|
|S Injury and poisoning (P)|
|T Causes of injury & poisoning (Q)|
U [X] External causes of morbidity & mortality
|Drugs & appliances (a-z lowercase)|
|a Gastro-intestinal system drugs|
|b Cardiovascular system drugs|
|c Respiratory system drugs|
|d Central nervous system drugs|
|e Drugs for infectious diseases|
|f Endocrine drugs|
|g Obs/gynae/urinary drugs|
|h Malignant & immunosuppressant drugs|
|j Musculoskeletal & joint drugs|
|k Eye drugs|
|l Ear, nose & oropharynx drugs|
|m Skin drugs|
|n Immunology drugs & vaccine|
|p Appliances & reagents etc|
|q Incontinence appliances|
|s Stoma appliances|
Knowing the chapter structure and headings can help provide a quick method of checking that the read code being used is the most appropriate.
Find and use the correct Read term
Decide which chapter the code is under, and determine level in hierarchy accordingly. Pick the correct type to ensure reliable output –
Chapter 1 is History and symptoms, where the systems chapters A-Z cover diagnoses. R can be used for a working diagnosis.
Avoid abbreviations which could result in several different descriptions
Avoid terms such as PAIN. ACUTE and CHRONIC which result in massive picklists
Use the combination of keyword and text string search to narrow down
Be specific but not too specific (e.g. CONTRACEPTION would not find any entries with keyword CONTRACEPTIVE therefore use CONTRACEP)
Set up and maintain a Read Formulary with practice-specific contents to ensure ease and consistency of data entry across the whole practice team
Preferred Term Codes and synonyms
In addition to the 5 digit Read Code, the system stores synonyms with additional 2 digit codes.
Code 00 indicates the preferred Read Code which is held in the Read Hierarchy, for example:
G111. 00 Rheumatic mitral insufficiency
Other synonyms have codes 11, 12, 13 and so on:
G111.12 Mitral regurgitation rheumatic
Read Code Searches
Search using: whole word, part word, part two words first 3 letters of each, part of two words reversed, unusual words (least common), abbreviations, site of, synonyms, eponyms
Do not rediagnose every time – use monitoring or review codes
Use correct dates use 1/1/03 if unknown or 1/1 for estimate
Or to save you searching around for the correct screen, you can go straight ahead and type a Read term using one of the shortcut Read
entry methods, and select from the Read dictionary.
The Vision system will then offer you one or more structured data areas where the record is stored, eg Blood Pressure.
A sub-set of the Read dictionary can be created as your practice formulary, consisting of your practice’s preferred Read descriptions
Many terms can be selected from the Read dictionary by entering a keyword, eg sinuses, anxiety.
When you enter a keyword, you are given a list of Read terms, from different parts of the Read dictionary, which are relevant to that keyword.
But less than half of all Read Terms have keywords. You can add your own keywords to Read terms.
Keywords are not simply parts of the Read term, but have been specifically attached to the Read term when the Read dictionary was designed, for example, IHD is the keyword to find Ischaemic heart disease codes.
Some Read terms have no keywords. These terms cannot be found by a keyword search, but can only be selected from the code hierarchy.
G3… is the code for IHD Ischaemic heart disease.
Ensure that all Read terms in your practice formulary have at least one keyword attached.
Use a simple, but effective keyword system which everybody in the practice is aware of and understands
Display by keyword – the user has entered a keyword of throat which displays terms re throat from different parts of the dictionary – codes beginning with 1 are symptoms, those with 4 laboratory procedures, and with alphabetic letters diagnoses by system, eg H for respiratory disease
Keywords and codes in Read
You can select from the Read dictionary either using keywords (Read’s or your own), or by code. The dictionary is a hierarchical structure consisting of five levels of codes, giving more detail as you go down. Some codes may have keywords, which are shortcut ways of selecting codes. The keywords listed here at those that are part of the Read dictionary. Here are some examples of the hierarchy:
Code Read Description Keyword
C0… Disorders of thyroid gland thyroid
C05.. Thyroiditis thyroiditi
C050. Acute thyroiditis
C0502 Abscess of thyroid abscess thyroid
H… Respiratory system disease respirator
H0… Acute respiratory infections acute, infection, respirator
H06.. Acute bronchitis and bronchiolitis
H060. Acute bronchitis bronchitis
H0602 Acute purulent bronchitis purulent
Display by Hierarchy – using Code H as starting point, the user has displayed sub-levels in the chapter H on respiratory system diseases
Letters and words
When searching for a particular code, you can search on just the first few letters of each word e.g. myo infar (for myocardial infarction)
Key term searching
Searching by typing in a key term eg
Abbreviations: IHD, CVA
Lay terms: stroke, heart attack, asthma, flu
Site/organ involved: clavicle – fracture clavicle
If at first you don’t succeed…
Occasionally, a phrase will fail to find a matching code e.g. typing in breast cancer will only produce FH: breast cancer BUT typing in breast neoplasm will work. Try a different word or medical phrase. Altering the word order may also have an effect.
The read codes can be searched by using the chapter headings as a starting point. e.g. to find asthma
Respiratory diseases H….
Chronic obstructive pulmonary disease H3…
Searches can also be carried out on different levels of the hierarchy.
e.g. All selected by searching on G30..
Acute myocardial Infarction G30..
Acute anterolateral infarction G300.
Acute inferolateral infarction G302.
Posterior myocardial infarction G304.
Searches that rely on grouping in the Read code hierarchy may produce anomalous results because they may include irrelevant or contradictory data.
e.g. searching on 19C..
Constipation symptom 19C..
Not Constipated 19C1.
Constipated NOS 19CZ.
The above search to identify patients with constipation would also count patients with the code for ‘not constipated’ This type of error can be avoided by inspecting the sub-hierarchies and excluding anomalous codes.
‘history of’ or ‘family history’ codes instead of diagnosis codes
e.g. Dermoid cyst, skin M2y46 Dermoid cyst, mouth J0840
Care must be taken when abbreviations are being coded as they vary from practice to practice and partner to partner. e.g. MS Mitral stenosis G110.
Multiple sclerosis F20..
Practices are encouraged to develop an agreed list of abbreviations to be used by all staff to avoid any such ambiguity.
There may be more than one Read code for certain conditions eg
Meningitis – tuberculous F004. (Nervous system & sense organ disease)
Tuberculous meningitis A130. (Infectious diseases)
The clinician will need to decide which Read code or chapter heading takes precedent. Care must be taken to agree a protocol for such scenarios so that data is recorded consistently within the practice.
NOS/OS Not otherwise specified and otherwise specified
NOS is used when no further information about the concept is known. For example, “Asthma NOS” means that “I know it’s asthma but have no idea about what type of asthma”. You could also capture this level of detail by using “Asthma” (H33..). Effectively these are the same thing.
“Asthma NOS” should only be used when the system is cross mapped to ICD9/ ICD10.
“Otherwise specified” means that more information about the concept is available but there is no definitive code available. For example, “Asthma OS” means that “I know what type of asthma it is, but there is no exact match in the Read codes ”.
free text qualifiers which may distort/reverse meaning
Consider the following: “asthma unlikely – seemed anxious”. The context is obvious, the patient is not asthmatic. However, if you enter this information on the clinical system by Read coding asthma (H33..) and adding “unlikely – seemed anxious” in free text, the computer will ignore the free text and the patient is labelled as asthmatic. Likewise the exclusion of a problem cannot be entered by qualifying the Read code with “no” or “not” in free text.
If the diagnosis is uncertain, the problem should either be entered as a symptom or as a working diagnosis (“R” codes).
source ? Team Associates
Included to allow cross-referencing with ICD9/10 OCPS4
NOS Not otherwise specified
OS Other specified
OS – Otherwise specified (codes end with y) This option indicates that enough is known to say categorically that it is not one of the other options at this level.
NFQ: Not further qualified
HFQ: However further qualified
EC: Elsewhere classified. Usually refers to an underlying cause of a disorder
EC – Elsewhere classified – This abbreviation refers to an entity that is classified elsewhere in the codes. It is usually the underlying cause of the particular disorder and is a hint that you may wish to code this cause as a second code to make it more specific.
NEC: Not elsewhere classified This means that specific varieties of this entity appear elsewhere in the classification. These will usually be shown on the picking list after a term key search. If none of the other matches the concept to be coded, use this code.
NOC: Not otherwise classifiable
NFQ NOT FURTHER QUALIFIED
NOC – Not otherwise classified
NOS NOT OTHERWISE SPECIFIED This option appears at the end of a list of entities at a given level. It should be selected it not enough detail is known about the data being recorded to choose one of the more specific options. It means the same as recording the code one level higher, but may be useful if a more detailed cross-reference code needs to be generated. For example, the term “asthma” alone means the same as “asthma NOS”.
[SO]: “site of” codes equate to chapter “Z” in OPCS4 and provide a way of coding the site of operation as a subsidiary code. (These codes are in Version 25-byte only).
[D] “diagnosis”: This code are used when a clinician has a working diagnosis which may later be identified as a defined disease entity. For example, “chest pain” is a symptom that may become a firm diagnosis after investigation where no further cause is found; such codes are often used as a “diagnosis” when it is not possible to be more precise.
[M] “morphology of neoplasms”: Codes containing this symbol are for recording the cell type of the neoplasm, and correspond to the morphology chapters in the ICD classifications.
[V] Version 2 terms that have been derived from ICD9/10 .
[X] Version 2 terms that have been derived from ICD9/10
Other Useful Read Terminology
A/R – Adverse reaction
[D] WORKING DIAGNOSIS Read Chapter R These codes are used when a
clinician has a working diagnosis which may later be identified as a defined disease entity. For example “dizziness” and “headache” are symptoms which may become a firm diagnosis after investigation but are often used as a “diagnosis” when it is not possible to be more precise.
FB – Foreign body
FH – Family History;
FH * Family History of malignancy
H/O – History of
[M] Morphology of neoplasms (e.g. Transitional Cell Ca Bladder) Read Chapter B.
Terms that contain this symbol are for recording the cell type of the neoplasm and correspond to the morphology chapters in the ICD classifications.
O/E – On examination
PH – Personal history of;
PH* Personal history of malignancy
[Q] Qualifier (Read 3 moves away from rigid hierarchical relationship concept and allows cross-linking between codes. Read Chapter Z.
[SO] SITE OF – Occurs in the sub-chapter &N… Codes with this included equate to chapter Z in OPCS4 and provide a way of coding the site of operation as a subsidiary code.
[V] Other factors affecting health – Occurs in sub-chapter ZV…Read Chapter Z. These codes correspond to the ICD10 chapter that records “supplementary factors influencing health status or contact with health services other than for illness” (for example “normal Pregnancy” ZV22 may affect the contact or health status other than illness).
[X] Derived from the ICD-10 updates. These use contemporary concepts and it is advised that these codes should be used for mental health and behavioural disorders (Eu replaced Chapter E) and for causes of morbidity/mortality (U replacing chapter T).
Notes summarising protocol (Trafford PCT)
A summary is a record of important relevant aspects of patient’s life events, from birth to present day, from hospital discharge letters to GP records, and to provide a database of information on the computer, which in turn can help to improve patient care.
GUIDE TO SUMMARISING
1. All notes need to be weeded and tagged by the relevant staff and placed in chronological order before any summaries can be started.
Responsible staff: _________________________________________________________
2. A summary is to be entered onto the electronic summary.
Responsible staff: ________________________________________________________
3. Summaries can be undertaken by a trained member of staff eg: nurse/doctor/trained receptionist /trained administrators or medical assistants.
Identified staff trained in electronic summarisation / Read codes: _________________
4. Respect the patient’s privacy, do not discuss work outside this is highly confidential. Do not take patient notes off site for summarising. If a patient is known to the summariser, someone else should undertake the summarising
Confidentiality agreements signed by note summarisers: ________________________
5. Preserve integrity and be aware of accuracy of manual record only work with one patient’s notes at a time – do not overlap different sets of notes. Refile details in a chronological manner. Also, over time medical records can become wrongly filed etc. If incorrect information / information relating to another patient is identified, highlight to a supervising member of staff.
6. Access to notes is important. Notes may have more than one file (1st/2nd or fat files) so ensure all the notes are together for the relevant patient. If they are not available or are out for surgery they must be handed to the summariser before being filed away.
7. It is essential to have a link GP or be able to liaise with the Practice Manager / supervisor if there are any queries with the patient’s notes. This can happen if the notes are illegible, if there is a wrong entry, if information to verify the entry cannot be located etc. Summarisers should never assume anything if they are unsurethey should always check with the link GP.
Identified GP/s: __________________________________________________________
Supervisor for note summarising: ____________________________________________
8. When going through letters, results, smears etc. be aware of the date; use the clinic date not the actual date of letter.
9. The day/month/year of diagnosis / intervention is to be entered on the summary, if not found enter for day and for the month (01/01) followed by year.
Never electronically record H/O diagnosis (history of), always enter the diagnosis with the date of diagnosis (not today’s date) or NK(date not known) and enter H/O in text.
10. All hospital operations, admissions, procedures and results are to be entered.
11.Enter children who are “on the child protection register’ and enter when removed from the child protection register.
12. Enter the Family History if you know the exact details. The Practice Nurse may be able to get the full information required; this then can also be entered on the Family History TEMPLATE.
13.Enter all known allergies in summary and electronically on TEMPLATE.
14. Enter significant social circumstances eg:death of close relative etc.
15 .It is advisable to use some form of indicator either on the notes or on the Lloyd George to state that the summary has been completed.
16. It is essential that summaries are maintained by staff thereafter.
ELECTRONIC SUMMARIES and Read CODES
Read codes are used to electronically record medical diagnoses, investigations, interventions etc. These are nationally approved and developed by a GP (Dr Read).
17. Once the manual summary is complete they can then be entered electronically onto the computer by Read codes.
18.Appropriate and standardised Read codes must be used for the diagnosis / investigation / intervention entered. These will be used for searches for the new GMS contract Clinical Quality Indicators.
19. On completion of the electronic summary, enter the Read code for “logging off” to state that the” Note summary on computer” is 9344 You will be requested to record the name of the summariser.If updating then use 9348.
20. It is crucial that electronic records and summaries are maintained thereafter – this may be the responsibility of all staff or designate staff. Validation of disease registers is recommended at regular agreed intervals.
QOF Disease Registers
See latest QOF Clinical Indicators Businesss Rules for specifics that should be recorded for each disease area & related tests & results.
Summary of Treatment Card’ This list contains some of the main diagnoses and interventions to be entered, but liaise with the doctors to decide what actually needs to be included within the practice AND determine where to record eg significant active / past and minor active / past.
CCF / LVD
Valvular Heart Disease AS/MS
Significant Family History
Chronic Fatigue Syndrome
Diagnostic Investigations eg ECG, Stress Test, Echo, CT Cholesterol, BS, HbA1c etc
Manic depressive disorde
Overdose/suicide attempt/self harm
Diabetes Type I/II
Notes Summarising Brief Procedure
Record all MAJOR DIAGNOSIS past or present including any chronic illness, that requires a referral to a hospital consultant and mental health disorders. The commencement date must be entered.
Record all FRACTURES , including site of fracture (in MINOR PAST)
Record all OPERATIONS and PROCEDURES that have taken place during their life.
Record all related ECGs; Echocardiograms; Heart Scans.
FEMALE PATIENTSrecord the following
PREGNANCIES (and birth details)
TERMINATION OF PREGNANCIES
Enter the last recorded entry for each of the following (consider diagnostic tests)
SMOKING STATUS / ALCOHOL STATUS
BLOOD GLUCOSE / HbA1c
Enter any recorded FAMILY HISTORY (specifically if possible )
ALLERGIES (record allergen)
IMMS FOR CHILDREN UNDER 16 and RECENT VACCS FOR OVER 16
RECALL DATES FOR NEW PT SCREEN AND SMEAR TESTS
IF CHILD ON CHILD PROTECTION REGISTER (removal from register should also be entered as a significant and active)
THERE IS NO NEED TO RECORD ALL MINOR COMPLAINTS THAT PATIENTS ATTEND SURGERY FOR ON A REGULAR BASIS EG: COLDS, FEVERS, RASHES, TONSILLITIS, BUMPS/SCRAPES, BRONCHITIS, TWISTS and SPRAINS ETC.
MAINTENANCE OF SUMMARISING
Unless stipulated otherwise, this will be maintained within the electronic patient record using the standardised, agreed Read codes should be used.
Any of the above items that the practice has agreed should be contained within a summary should be recorded by the clinician seeing the patient within a routine consultation or chronic disease monitoring. This may involve using a specific template within a clinical system. Alternatively, the clinician may highlight the information that needs to be recorded for a trained administrator who is familiar with Read codes to enter onto the computer.
The practice should have a system of highlighting any of the above diagnoses / investigations / interventions that are documented within hospital letters or test results. These should be entered onto the clinical system by either a clinician or administrator familiar with Read coding.
At regular agreed intervals (ideally once a year), disease registers should be validated by running searches on patients with specific agreed Read codes recorded against relevant medication searches.
A suggested process for validation can be obtained from the Prescribing Team at Trafford PCT on 873 9525.
Key aspects of QuIP DES as laid out in the specification are:
It is a plan agreed by the PCT and contractor
It must include a protocol for how the summarsising is to be done and arrangements for ongoing maintenance. Non-medical personnel must
a. be fully trained,
b. not take medical records away from the premises,
c. have appropriate access to GP performers when they have queries,
d. sign a confidentiality agreement,
e. be appropriately supervised
You should use the codes
9348: Computer summary updated
9344: Note summary on computer
PB SCHP Aug 2009
Can enter Read codes directly in the clinical system by preceding with #
Enter all major diagnoses on the problem screen.
Make a seperate entry under medical history with the date of diagnosis (use 010103 if unknown), and episode whether first ever or continuing
…link all assosciated items in the medical history to the problem eg CABG to IHD
Ensure patient on appropriate disease registers by entering correct code
if deleting a wrongly coded problem need to delete 3 entries … Medical history, problem, and register entries
Do not enter presumptive diagnoses as definite ones until confirmed
Search using: whole word, part word, part two words first 3 letters of each, part of two words reversed, unusual words (least common), abbreviations, site of, synonyms, eponyms
Do not rediagnose every time – use monitoring or review codes
Use correct dates use 1/1/03 if unknown or 1/1 for estimate
Confirm or refute by spirometry.
Ensure on disease register, problem list and medical history (with diagnosis date).
Link other associated medical histories to the problem eg exacerbations.
Record Smoking status within last 15m
Only include active asthmatics on treatment within last 12 m
Asthmatics >8 newly diagnosed since 1/4/03 need confirmation of diagnosis. Peak flow variability 20 percent and > over 60 l/min or spirometry/reversibility
>16 years on 1 Apr. Gestational diabetes and IGT excluded from QOF but keep these patients under annual review. Record whether type 1 or type 2.
Record foot checks Eye checks and neuropathy testing within last 12 m
Needs cancer care review within 6m if diagnosed after 1/4/04.
BCC and SCC dont count. Diagnoses must be on the problem list.
There must be an entry under medical history and on disease register with a date of diagnosis , whether first ever or new event.
Always use malignant neoplasm of… code not Ca
Severe Enduring Mental Health only – schizophrenia, BPD, schizoaffective disorder.
All diagnoses must be on the problem list and there must be an entry in the medical history with the date of diagnosis.
Other associated problems should be linked to the problem
Review following: seizure type and frequency, date of last seizure, drugs and doses, drug side effects, management plan for coming year Diagnosis in problem list/ Entry under medical history with date/ associated histories linked to the problem
Exclude patients from register with unproven ?TIA etc in past. Record whether haemorrhagic or infarct.
Put on problem list/Enter in medical history with diagnosis date/ Link this entry to problem inc whether as first ever event.
All new strokes need CT/MRI – record and link to problem.
Ensure on disease register. Avoid VBI when summarising.
Barnsley PCT Read Code / Notes Summarising Policy
As a general rule – any conditions that would be included in an insurance medical report.
Entering Information in EMIS LV:
In EMIS this information should be added to the medical record as follows:
1. Choose “Add”
2. Enter as accurate a date as possible to reflect the date of occurrence/onset
3. Enter correct code (refer to Read Code Guidelines): following the hierarchy system (see Choosing the Right Chapter) select the most accurate code
Any problem that may need to be taken into account when treating a patient
some congenital defects
major surgery/major trauma (practices may choose to include all fractures and operations)
Any problem that is not of continuing importance
minor operations e.g. appendicectomy
minor fractures / trauma
minor self-limiting illness
melanocytic naevus, skin tags
All continuing health problems / chronic diseases
e.g. CHD, OA, Rheumatoid Arthritis, dementia, psychotic illness, glaucoma, malignancies, hypothyroidism, epilepsy, allergies, hypertension, sensory impairments
Past Medical History
A problem that has occurred in the past but is not currently a probleme.g. TIA, CVA
Operations e.g. hysterectomy
Concluded episodes e.g. myocardial infarction, depressive illness, pneumonia
After a set of notes has been fully summarised and added to the computer this needs to be dated and coded appropriately:
Lloyd George culled and summarised 9313.
Notes summary on computer 9344.
NHS Connecting for Health CfH / National Programme for IT NPfIT
Connecting for health.nhs.uk
NPfIT should be killed off says National Audit Office – the Register May 2011
Following an appointment with his GP, the patient is given some paperwork containing a reference number, a password and a list of hospitals that the GP has selected from a list provided by the PCT and which would be suitable for the patient.
The patient is also given information about the hospitals in question, including information as basic as parking facilities to more clinically relevant information such as waiting time and performance ratings.
The patient books the appointment in the hospital of their choice. This can be done either through the GP surgery, by telephone using a special number, through the Internet, and sometimes by calling the clinic directly.
The referral documents are placed by the GP into the system using the patient’s reference number as an identifier. This means that the consultant can recall the information on his screen rapidly and review the appropriateness of the referral or adjust the priority status.
Choice and Book and Patient Choice
How the NHS has failed its promises on patients choice dailymail.co.uk
Direct secure and rapid transfer of patients’ electronic health records between GP practices.
Once the patient is accepted and his/her identity has been matched using the Personal Demographic Service (PDS) a message is sent to the previous practice requesting a copy of the patient’s EHR (if that practice also GP2GP-enabled).
The previous practice locates the patient and sends an acknowledgement stating whether or not it is able to provide the EHR extract.
If it is able to do so, then the EHR extract message is generated from the patient health record held on the GP clinical system and subsequently sent to the new practice for integration into its own GP clinical system
Enables prescribers to generate and send prescriptions electronically (via the EPS) to a dispenser (pharmacy) of the patient’s choice reducing paper administration and making the prescribing and dispensing process safer and more convenient for patients and staff.
Information to be included in an electronic record
1. Basic demographic data
date of birth
registered GP/practice identifier
date of registration with the practice
date of leaving
Spoken language/ country of origin
2. All acute and repeat prescriptions
3. Clinical Data:
Test results and procedures except those that do not have ongoing significance
Investigations such as x-rays and other imaging, ECGs, endoscopy, echocardiogram
All diseases /conditions (when adding retrospective data refer to the GMC Good Practice Guidelines for Electronic Patient Records for clarification of what to include)
Fractures / trauma
Sensory impairments / disability
Social conditions of relevance e.g. on at risk register, bereavement, divorce, death of a spouse
Out patient referrals
Screening procedures: mammography / cervical cytology
Obstetric / childbirth details
Terminations / Abortion
4. Risk factors as defined by practice protocols and clinical guidelines
5. Cause of death
see also medical records, communication, safe-prescribing etc
out of date – put more stuff here
Data Protection Information Governance Caldicott Freedom of Information Medical Records
XML Extensible Mark-up Language
Open industry-standard language for organising, storing and exchanging documents and data.
Plain-text, meta-language = language for defining mark-up languages.
Not tied to any programming language,operating system, or software vendor.
Any application that supports XML can access and work with data in the new file format.
The application does not need to be part of any particular operating system or propriety software product
It offers the same kind of benefits to businesses and industries that HTML does to the Internet, in terms of enabling them to share and reuse data and documents.
One of the great strengths of XML is that it enables this separation of content from presentation.
It not only makes data transportable and easy to share, but allows the same data to be displayed on a variety of devices, so that a document can also be read, for instance, on a desktop PC, a PDA or a smart phone.