Transcript Read Code Presentation - First Practice Management

Read Code Training
- Effective use of Read Codes PRIMIS
NHS Cumbria
The aims of this session…

Understand the Read Code hierarchy

To build confidence in using read codes

Find most appropriate read code

Know which codes to use for which purpose
2
Why Read Code?

Accurate data entry helps improve patient care indirectly by
ensuring that clinicians are always basing their judgements on the
best possible information available at the time
Allergies / Adverse
Reactions
Family History
Relevant Tests &
Investigations
Immunisations
Past Symptoms

Diagnoses
Operations
Monitoring
Accurate data entry will enable the transition to Paperlight working
and a complete electronic patient record

Facilitates future audit and reporting requirements

QOF
3
What are Read Codes?


Set of clinical codes designed for Primary Care
to record the every day care of a Patient
Developed by Dr James Read (GP,
Loughborough)

Recognised standard for General Practice

Hierarchical structure
4
Key aspects to understanding
Read Codes

Sorted into categories and chapters

Hierarchical structure

Combination of letters and numbers

CaSe-SeNsItIve

Maximum of 5 characters
5
Read Code Chapters


Three categories:
 Diagnoses
 Processes of Care
 Medication
These categories are further divided into
sub-chapters
6
Read Code Chapters cont’d



Diagnoses
 Codes all begin with a capital letter
 e.g. H33 (Asthma), C10E (Type 1 diabetes mellitus)
Processes of Care
 Codes all begin with a number
 Used to record history, symptoms, examinations, tests,
screening, operations and patient administration etc
 e.g. 44P (Serum cholesterol), 65E (Influenza vaccination)
Medication
 Codes all begin with a small case letter
 Automatically entered into the patient record when any
treatment is prescribed
 e.g. bu25 (Aspirin 75mg tablets)
7
Processes of Care
Diagnoses
Medication
0
A
Infectious /parasitic disease
‘a
Gastro-intestinal
B
Neoplasms
.b
Cardiovascular
C
Endocrine, Nutritional etc
.c
Respiratory
D
Diseases of the blood
.d
Central Nervous System
E
Mental disorders
.e
Drugs used in Infections
F
Nervous System
.f
Endocrine drugs
G
Circulatory System
.g
Obs, gynae, UTI
H
Respiratory System
.h
Chemotherapy etc
J
Digestive System
ii
Haemotology / dietetic
K
Genitourinary System
.j
Musculoskeletal
L
Compl. Of child birth etc
.k
Eye
M
Skin / sub-cutaneous tissue
.l
ENT
N
Musculoskeletal diseases
.m
Skin
P
Congenital conditions
.n
Immunology / vaccines
Q
Perinatal conditions
.o
Anaesthetic
R
Signs, ill-defined conditions
.p
Appliances & Reagants
S
Injury & poisoning
.q
Incontinence appliances
T
Causes injury & poisoning
.s
Stoma appliances
U
Ext. causes morbidity / mortality
.u
Contrast media
Z
Unspecified conditions
.y
Drug release administration
1
2
3
4
5
6
7
8
9
Occupations
History / Symptoms
Examinations & Signs
Diagnostic procedures
Laboratory procedures
Radiology / Physics in Medicine
Preventive procedures
Operations, procedures, sites
Other therapeutic procedures
Administration
8
Read Code Hierarchy


There are different levels of detail within each read code
chapter (5-byte = up to 5 levels)
These different levels of detail are organised logically by
means of the Read Code Hierarchy

“Higher level” codes are more general

“Lower level” codes are more detailed and precise

The first digit of a Read Code says a lot about the
meaning of the Read Code, and it is important to be
aware of this when selecting Read Codes to record data
9
Read Code Hierarchy cont’d
Example:
C
Endocrine, nutritional, metabolic and immunity disorders
C1
Other endocrine gland diseases
C10
Diabetes mellitus
C10E Type 1 diabetes mellitus
C10E7 Type 1 diabetes mellitus with retinopathy

Could refer to these as “families” of codes – Parent and Child
Codes

C10 is a parent code to C10E. It is also a child code to C1

Each code begins the same way as the one before but contains an
extra layer of detail

This pattern repeats across all chapters

Enables data to be entered at the required level of detail
10
663N0 Asthma
causing night
wakening
6637 Inhaler
technique
observed
663N1 Asthma
disturbs sleep
weekly
663N Asthma
disturbing sleep
C10E0 Type 1
Diabetes mellitus
with renal
complications
C10E7 Type 1
Diabetes mellitus
with retinopathy
C10E Type 1
Diabetes mellitus
663 Respiratory
disease
monitoring
667 Epilepsy
monitoring
66H Rheumatology
disorder monitoring
C10F Type 2
Diabetes mellitus
C10 Diabetes mellitus
C1 Other endocrine gland diseases
66 Chronic disease
monitoring
C Endocrine, nutritional,
metabolic and immunity
disorders
6 Preventative
procedures
Read
Code
Tree
11
Combination of letters and numbers


Read codes are only made up of the following
characters:

Letters (upper & lower case)

Numbers
Users may have noticed the % sign sometimes
following codes in MIQUEST queries and QOF criteria.
This is used for administrative purposes to indicate that
the rest of the hierarchy is included. e.g. C10% means
every code beginning “C10”.
12
Case-Sensitive

Read Codes are case sensitive and entering the code
incorrectly can completely alter the meaning

Be careful!
Example:
8HTK. Referral to stop-smoking clinic
8HTk. Referral to diabetic eye clinic
9H8.. On severe mental illness register
9h8.. Exception reporting: cancer quality indicators
13
Maximum of 5 characters

Read codes can be one to five characters long

The more characters, the greater level of detail in the code

Referred to as “5-Byte” read codes

Users may have noticed some read codes followed by a “-0”, “1”, or “-2” etc


This is used to denote a Preferred or Synonymous Term
and is called the “Term Code”
It does not constitute the main body of the Read Code
14
Preferred and Synonymous Terms


Preferred terms are the main descriptions
Synonymous terms are alternate descriptions of the
Preferred term
Example:
Acute MI
Attack – Heart
Coronary Thrombosis
Heart Attack
G30
G30-1
G30-2
G30-4
P
S
S
S
15
How to select the ‘right’ Read Code
Direct code entry


Entering the code itself if it is known (e.g. C10 for Diabetes)
Accurate and quick – if you know the code!
Searching by keyword



Entering the full term, first few letters, or abbreviation (e.g. diabetes mellitus, diab,
diab mel, dm for Diabetes), and then making a selection from the list of codes the
clinical system has provided based on the keyword entered
Being more specific will bring up a more concise list
Simplest and most common approach – user has to decide which code description is
most accurate and which chapter the code should originate from
Browsing the Read Code hierarchy


Searching for codes by moving up and down the Read Code hierarchy until the
appropriate code is found. E.g. choosing a chapter from which to start and then find
the appropriate read code by “drilling down” through the hierarchy
More reliable - as correct chapter is chosen initially but requires some knowledge of
medical terminology to navigate read code hierarchy
Using Templates/Guidelines

Allows quick and standard data entry
16
Templates/Guidelines


For routine data entry, templates can be very useful to:
 Speed data entry
 Ensure that all appropriate information about a patient is
obtained (especially useful in clinic environment)
 Ensure that patient information is recorded consistently across
the practice
However…
 No use for non-routine data entry
 Limited to a pre-defined list of read codes
 Any error in the template will be reproduced in all subsequent
uses of the template
17
All information entered into the Patient Record is done so
within a Context whether it be recording a diagnosis,
Processes of Care
Diagnoses
screening or family history.
Chapters allowMedication
users to keep this
0
Occupations
A
Infectious /parasitic disease
‘a
Gastro-intestinal
sense
of context when
Read
coding.
1
2
History / Symptoms
Examinations & Signs
B
Neoplasms
.b
Cardiovascular
C
Endocrine, Nutritional etc
.c
Respiratory
D
Diseases of the blood
E
F
Asthma
(Diagnosis) – H33 G
3
Diagnostic procedures
H
4
5
6
.f
Endocrine drugs
Circulatory System
.g
Obs, gynae, UTI
Respiratory System
.h
Chemotherapy etc
J
Digestive System
ii
Think Chapters,
think
Context!
K
Genitourinary System
.j
Radiology / Physics in Medicine
Preventive procedures
Other therapeutic procedures
Administration
Haemotology / dietetic
Musculoskeletal
L
Compl. Of child birth etc
.k
Eye
M
Skin / sub-cutaneous tissue
.l
ENT
N
Musculoskeletal diseases
P
Congenital conditions
.n
Immunology / vaccines
U
Ext. causes morbidity / mortality
.u
Contrast media
Z
Unspecified conditions
.y
Drug release administration
Q
R
S
T
9
Nervous System
Laboratory procedures
Asthma leaflet
7
Operations, procedures, sites
given – 8CE2
8
.d
Central
Suspected asthma
– Nervous System
Mental disorders
.e
Drugs used in Infections
1J70
Asthma
monitoring – 663
.m
Skin
For
Example,
take the
word
Asthma. This
Perinatal
conditions
.o
Anaesthetic
appears
inconditions
more than
read& code
Signs, ill-defined
.p one
Appliances
Reagants
Injury & poisoning
.q
appliances
chapter
depending on
theIncontinence
context
from
Causes injury
& poisoning
.s
Stoma appliances
which
the
information
originates.
Seen in Asthma Clinic – 9N1d
18
Useful Read Code Abbreviations
O/E
C/O
H/O
FH
NOS
OS
NFQ
HFQ
NEC
NOC
[SO]
[D]
[M]
[V]
[X]
on examination
complaining of
history of
family history of
not otherwise specified
otherwise specified
not further qualified
however further qualified
not elsewhere classified
not otherwise classifiable
site of
working diagnosis
morphology of neoplasms
(from ICD)
(from ICD-10)
19
Common Errors


Without an understanding of Read Codes it is
very easy to enter patient information incorrectly
onto the Clinical System
Observe the following examples of common read
coding errors and consider what measures have
been taken in your practice to prevent them
from occurring
20
Common Errors 1
B
One of the most
common
Medication
errors with Read Coding
Infectious involves
/parasitic disease
‘a
Gastro-intestinal
selecting
a read code
Neoplasmsfrom an inappropriate
.b
Cardiovascular
chapter
C
Endocrine, Nutritional etc
.c
Respiratory
D
Diseases of the blood
.d
Central Nervous System
E
Mental disorders
1434 – H/O Diabetes F
Mellitus
Diagnostic procedures
G
Nervous System
Processes of Care
Diagnoses
0
A
1
2
3
Occupations
History / Symptoms
Examinations & Signs
5
Laboratory procedures
Radiology / Physics in
Medicine
The
consequences
Circulatory System
.g
Obs, gynae, UTI
K
Chemotherapy etcof
a Diagnosis
Digestive
System Mellitusii as a History
Haemotology of
/ dietetic
Diabetes
Genitourinary
System
.j
Musculoskeletal
Diabetes
L
Compl. Of child birth etc
H
4
C10 – Diabetes
.e
Drugs used in Infections
Mellitus.f
Endocrine drugs
J
Respiratory
SystemRecording
.h
Example:
.k
Eye
of making
this
sort
of mistaketissue
are serious.
M
Skin
/ sub-cutaneous
.l
ENT
6
procedures
N
Musculoskeletal
diseases
Skin as a
1.Preventive
The record
will be inaccurate.
The patient
will not.mbe coded
Congenital conditions
.n
Immunology / vaccines
diagnosed diabetic. P
7
2.sites The patient will not be counted on the Diabetic Register and may not be
R
Signs, ill-defined conditions .p
Appliances & Reagants
monitored appropriately.
8
9
Operations, procedures,
Other therapeutic
3.procedures
Even if the
Q
Perinatal conditions
.o
Anaesthetic
S
Injury & poisoning
.q
Incontinence appliances
.u
Contrast media
Practice do
monitor
the patient appropriately,
the work will not
T
Causes injury & poisoning
.s
Stoma appliances
be rewarded in the QOF.
Administration
4.
U
DO NOT USE H/O Codes
Z
Ext. causes morbidity /
tomortality
record a current
Unspecified conditions
diagnosis!
.y
21
Drug release administration
Common Errors 2
Processes of Care
Diagnoses
Medication
0
A
Infectious /parasitic disease
‘a
Gastro-intestinal
B
Neoplasms
.b
Cardiovascular
C
Endocrine, Nutritional etc
.c
Respiratory
D
Diseases of the blood
.d
Central Nervous System
E
Mental disorders
.e
Drugs used in Infections
F
Nervous System
.f
Endocrine drugs
K
Genitourinary System
.j
Musculoskeletal
L
Compl. Of child birth etc
.k
Eye
M
Skin / sub-cutaneous tissue
.l
ENT
P
Congenital conditions
.n
Immunology / vaccines
Operations, procedures,
sites
Q
Perinatal conditions
.o
Anaesthetic
R
Signs, ill-defined conditions
.p
Appliances & Reagants
Other therapeutic
procedures
S
Injury & poisoning
.q
Incontinence appliances
T
Causes injury & poisoning
.s
Stoma appliances
Administration
U
Ext. causes morbidity /
mortality
.u
Contrast media
Z
Unspecified conditions
.y
Drug release administration
1
Occupations
History / Symptoms
This issue of confusing
2
Examinations
& Signs can
Read
Code
chapters
be applied to entering a
morbidity
instead
of an
3
Diagnostic
procedures
immunisation or test
4
5
6
7
8
9
Laboratory procedures
Radiology / Physics in
Medicine
Preventive procedures
G
H
J
A37 – Tetanus
Example:
Recording.ga Diagnosis
of
Circulatory System
Obs, gynae, UTI
Tetanus
of a.h Vaccination
Respiratory instead
System
Chemotherapyfor
etc
Tetanus
Digestive System
ii
Haemotology / dietetic
– Tetanusdiseases
Vaccination
N 656 Musculoskeletal
.m
Skin
22
Common Errors 3
Processes of Care
Diagnoses
Medication
0
A
Infectious /parasitic disease
‘a
Gastro-intestinal
B
Neoplasms
.b
Cardiovascular
1
2
3
4
5
6
7
8
14Y1 –
Occupations
History / Symptoms
Examinations & Signs
Diagnostic procedures
C
Endocrine,
Nutritional
etc
.c
Example:
recording
neonatal
D
Diseases
of the blood record
.d or
problems
to Mother’s
recording
birth
details in the
E
Mental
disorders
.e
baby’s
record
F
Nervous System
.f
Respiratory
Central Nervous System
Drugs used in Infections
Endocrine drugs
G
Circulatory System
.g
H
Respiratory System
– Forceps
.h L395
Chemotherapy
etc
J
Digestive System
ii
K
Genitourinary System
.j
Radiology / Physics in
Medicine
L
Compl. Of child birth etc
.k
M
Skin / sub-cutaneous tissue
.l
ENT
Preventive procedures
N
Musculoskeletal diseases
.m
Skin
P
Congenital conditions
.n
Immunology / vaccines
Q
Perinatal conditions
.o
Anaesthetic
R
Signs, ill-defined conditions
.p
Appliances & Reagants
S
Injury & poisoning
.q
Incontinence appliances
Causes injury & poisoning
.s
Stoma appliances
U
Ext. causes morbidity /
mortality
.u
Contrast media
Z
Unspecified conditions
.y
Drug release administration
Laboratory procedures
Operations, procedures,
sites
Other therapeutic
procedures
Born
by Forceps
Administration
(For 9the Child)
delivery
T
Obs, gynae, UTI
delivery
Haemotology / dietetic
Musculoskeletal
(For the Mother)
Eye
23
Common Errors 4
Processes of Care
Diagnoses
Medication
0
A
‘a
Gastro-intestinal
.b
Cardiovascular
.c
Respiratory
.d
Central Nervous System
1
2
3
4
Occupations
Example:
recording
male
B
Neoplasms
problems/codes
on female
History / Symptoms
C
Endocrine, Nutritional etc
recordsD (andDiseases
vice versa)
of the blood
Examinations & Signs
7C110 – Bilateral
Diagnostic procedures
vasectomy for
contraception
Laboratory procedures
(For the Man)
5
6
7
8
9
Infectious /parasitic disease
Radiology / Physics in
Medicine
E
Mental disorders
.e
Drugs used in Infections
F
Nervous System
.f
Endocrine drugs
G
Circulatory System
.g
Obs, gynae, UTI
H
Respiratory System
.h
Chemotherapy etc
J
Digestive System
ii
Haemotology / dietetic
K
Genitourinary System
6124
L
.j
Musculoskeletal
– Partner
had
Compl. Of child birth
etc
.k
Eye
vasectomy
M
Skin / sub-cutaneous tissue
.l
ENT
P
61G – Contraception:
Musculoskeletal diseases
.m
Skin
vasectomy
Congenital conditions
.n
Immunology / vaccines
Operations, procedures,
sites
Q
Perinatal conditions
(For
R
Signs, ill-defined conditions
.p
Appliances & Reagants
Other therapeutic
procedures
S
Injury & poisoning
.q
Incontinence appliances
T
Causes injury & poisoning
.s
Stoma appliances
Administration
U
Ext. causes morbidity /
mortality
.u
Contrast media
Z
Unspecified conditions
.y
Drug release administration
Preventive procedures
N
Anaesthetic
the.oWoman)
24
Common Errors cont’d

Using a diagnosis code to record that a patient does not have
a particular condition by typing “not present” or something to
that effect in the text box
Example:
C10

Diabetes Mellitus
Not present
Using the text box to record data that should be separately
read coded
Example:
137R
Current smoker
Advised patient to stop smoking
instead of:
137R
Current smoker
8CAL
Smoking cessation advice
25
Common Errors cont’d
These examples are bad practice because:

codes have been used in the wrong context and imply a
different meaning

as far as the clinical system is concerned, whatever is typed
in free text does not affect the application of the read code


information recorded in free text cannot be searched on
later for audit and reporting requirements because it is not
read coded
any values recorded in free text do not filter into the
appropriate location on the system for reference purposes
(e.g. Blood Pressure, eGFR) and so record is incomplete
26
General Guidance on Read Codes

Understand the Read Code Structure and context of codes when
using them

Use Read Code guidance where available

Templates/Guidelines facilitate multiple data entries in a standard
and quick way

Use diagnosis codes rather than H/O codes for current diagnoses

Don’t use a diagnosis code with free text to record a negative
entry

Once a diagnosis code has been recorded, use a procedure code
rather than the diagnosis code for future monitoring

Be as specific as you like when recording Read Codes, the
structure allows this

Try not to use in-house created codes or synonymous terms
27
Recommendations for Practices






Staff Training
Know your Read Codes
Keep it simple & relevant
Be consistent
Procedures and protocols
Clinicians to record their
own consultations
28
The aims of this session…

Understand the Read Code hierarchy

To build confidence in using read codes

Find most appropriate read code

Know which codes to use for which purpose
29
Thank you for listening
Any questions?
30