1. - Effective use of Read Codes -
Read Code Training
- Effective use of Read Codes -
PRIMIS
NHS Cumbria

2. 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

3. Allergies / Adverse Reactions Relevant Tests & Investigations
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
Accurate data entry will enable the transition to Paperlight working and a complete electronic patient record
Facilitates future audit and reporting requirements
QOF
Family History
Operations
Allergies / Adverse Reactions
Relevant Tests & Investigations
Immunisations
Past Symptoms
Diagnoses
Monitoring

4. 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

5. Key aspects to understanding Read Codes
Sorted into categories and chapters
Hierarchical structure
Combination of letters and numbers
CaSe-SeNsItIve
Maximum of 5 characters

6. Read Code Chapters Three categories: Diagnoses Processes of Care
Medication
These categories are further divided into sub-chapters

7. 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)

8. Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration

9. 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

10. 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

11. Read Code Tree 663N0 Asthma causing night wakening
663N1 Asthma disturbs sleep weekly
C10E0 Type 1 Diabetes mellitus with renal complications
C10E7 Type 1 Diabetes mellitus with retinopathy
6637 Inhaler technique observed
663N Asthma disturbing sleep
C10E Type 1 Diabetes mellitus
C10F Type 2 Diabetes mellitus
663 Respiratory disease monitoring
667 Epilepsy monitoring
66H Rheumatology disorder monitoring
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

12. 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”.

13. 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

14. 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

15. Preferred and Synonymous Terms
Preferred terms are the main descriptions
Synonymous terms are alternate descriptions of the Preferred term
Example:
Acute MI G30 P
Attack – Heart G30-1 S
Coronary Thrombosis G30-2 S
Heart Attack G30-4 S

16. 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

17. 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

18. Think Chapters, think Context!
All information entered into the Patient Record is done so within a Context whether it be recording a diagnosis, screening or family history. Chapters allow users to keep this sense of context when Read coding.
Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration
Suspected asthma – 1J70
Asthma (Diagnosis) – H33
Think Chapters, think Context!
Asthma monitoring – 663
Asthma leaflet given – 8CE2
For Example, take the word Asthma. This appears in more than one read code chapter depending on the context from which the information originates.
Seen in Asthma Clinic – 9N1d

19. 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)

20. 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

21. Common Errors 1
One of the most common errors with Read Coding involves selecting a read code from an inappropriate chapter
Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration
C10 – Diabetes Mellitus
1434 – H/O Diabetes Mellitus
Example: Recording a Diagnosis of Diabetes Mellitus as a History of Diabetes
The consequences of making this sort of mistake are serious.
The record will be inaccurate. The patient will not be coded as a diagnosed diabetic.
The patient will not be counted on the Diabetic Register and may not be monitored appropriately.
Even if the Practice do monitor the patient appropriately, the work will not be rewarded in the QOF.
DO NOT USE H/O Codes to record a current diagnosis!

22. Common Errors 2
Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration
This issue of confusing Read Code chapters can be applied to entering a morbidity instead of an immunisation or test
A37 – Tetanus
Example: Recording a Diagnosis of Tetanus instead of a Vaccination for Tetanus
656 – Tetanus Vaccination

23. Common Errors 3
Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration
Example: recording neonatal problems to Mother’s record or recording birth details in the baby’s record
L395 – Forceps delivery
(For the Mother)
14Y1 – Born by Forceps delivery
(For the Child)

24. Common Errors 4
Processes of Care
Diagnoses
Medication
Occupations A
Infectious /parasitic disease ‘a
Gastro-intestinal B
Neoplasms .b
Cardiovascular 1
History / Symptoms C
Endocrine, Nutritional etc .c
Respiratory D
Diseases of the blood .d
Central Nervous System 2
Examinations & Signs E
Mental disorders .e
Drugs used in Infections F
Nervous System .f
Endocrine drugs 3
Diagnostic procedures G
Circulatory System .g
Obs, gynae, UTI H
Respiratory System .h
Chemotherapy etc 4
Laboratory procedures J
Digestive System ii
Haemotology / dietetic K
Genitourinary System .j
Musculoskeletal 5
Radiology / Physics in Medicine L
Compl. Of child birth etc .k
Eye M
Skin / sub-cutaneous tissue .l
ENT 6
Preventive procedures N
Musculoskeletal diseases .m
Skin P
Congenital conditions .n
Immunology / vaccines 7
Operations, procedures, sites Q
Perinatal conditions .o
Anaesthetic R
Signs, ill-defined conditions .p
Appliances & Reagants 8
Other therapeutic procedures S
Injury & poisoning .q
Incontinence appliances T
Causes injury & poisoning .s
Stoma appliances 9
Administration U
Ext. causes morbidity / mortality .u
Contrast media Z
Unspecified conditions .y
Drug release administration
Example: recording male problems/codes on female records (and vice versa)
7C110 – Bilateral vasectomy for contraception
(For the Man)
6124 – Partner had vasectomy
61G – Contraception: vasectomy
(For the Woman)

25. 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:
instead of:
137R Current smoker Advised patient to stop smoking
137R Current smoker
8CAL Smoking cessation advice

26. 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

27. 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

28. Recommendations for Practices
Staff Training
Know your Read Codes
Keep it simple & relevant
Be consistent
Procedures and protocols
Clinicians to record their own consultations

29. 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

30. Thank you for listening Any questions?