Read Code Training Effective use of Read Codes

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

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

The aims of this session… n Understand the Read Code hierarchy n To build

The aims of this session… n Understand the Read Code hierarchy n To build confidence in using read codes n Find most appropriate read code n Know which codes to use for which purpose 2

Why Read Code? n Accurate data entry helps improve patient care indirectly by ensuring

Why Read Code? n 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 n Diagnoses Operations Monitoring Accurate data entry will enable the transition to Paperlight working and a complete electronic patient record n Facilitates future audit and reporting requirements n QOF 3

What are Read Codes? n n Set of clinical codes designed for Primary Care

What are Read Codes? n n Set of clinical codes designed for Primary Care to record the every day care of a Patient Developed by Dr James Read (GP, Loughborough) n Recognised standard for General Practice n Hierarchical structure 4

Key aspects to understanding Read Codes n Sorted into categories and chapters n Hierarchical

Key aspects to understanding Read Codes n Sorted into categories and chapters n Hierarchical structure n Combination of letters and numbers n Ca. Se-Se. Ns. It. Ive n Maximum of 5 characters 5

Read Code Chapters n n Three categories: n Diagnoses n Processes of Care n

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

Read Code Chapters cont’d n n n Diagnoses n Codes all begin with a

Read Code Chapters cont’d n n n Diagnoses n Codes all begin with a capital letter n e. g. H 33 (Asthma), C 10 E (Type 1 diabetes mellitus) Processes of Care n Codes all begin with a number n Used to record history, symptoms, examinations, tests, screening, operations and patient administration etc n e. g. 44 P (Serum cholesterol), 65 E (Influenza vaccination) Medication n Codes all begin with a small case letter n Automatically entered into the patient record when any treatment is prescribed n e. g. bu 25 (Aspirin 75 mg tablets) 7

Processes of Care Diagnoses Medication 0 A Infectious /parasitic disease ‘a Gastro-intestinal B Neoplasms

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 Otherapeutic procedures Administration 8

Read Code Hierarchy n n There are different levels of detail within each read

Read Code Hierarchy n n 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 n “Higher level” codes are more general n “Lower level” codes are more detailed and precise n 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 C 1

Read Code Hierarchy cont’d Example: C Endocrine, nutritional, metabolic and immunity disorders C 1 Other endocrine gland diseases C 10 Diabetes mellitus C 10 E Type 1 diabetes mellitus C 10 E 7 Type 1 diabetes mellitus with retinopathy n Could refer to these as “families” of codes – Parent and Child Codes n C 10 is a parent code to C 10 E. It is also a child code to C 1 n Each code begins the same way as the one before but contains an extra layer of detail n This pattern repeats across all chapters n Enables data to be entered at the required level of detail 10

663 N 0 Asthma causing night wakening 6637 Inhaler technique observed 663 N 1

663 N 0 Asthma causing night wakening 6637 Inhaler technique observed 663 N 1 Asthma disturbs sleep weekly 663 N Asthma disturbing sleep C 10 E 0 Type 1 Diabetes mellitus with renal complications C 10 E 7 Type 1 Diabetes mellitus with retinopathy C 10 E Type 1 Diabetes mellitus 663 Respiratory disease monitoring 667 Epilepsy monitoring 66 H Rheumatology disorder monitoring C 10 F Type 2 Diabetes mellitus C 10 Diabetes mellitus C 1 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 n n Read codes are only made up of

Combination of letters and numbers n n Read codes are only made up of the following characters: n Letters (upper & lower case) n 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. C 10% means every code beginning “C 10”. 12

Case-Sensitive n Read Codes are case sensitive and entering the code incorrectly can completely

Case-Sensitive n Read Codes are case sensitive and entering the code incorrectly can completely alter the meaning n Be careful! Example: 8 HTK. Referral to stop-smoking clinic 8 HTk. Referral to diabetic eye clinic 9 H 8. . On severe mental illness register 9 h 8. . Exception reporting: cancer quality indicators 13

Maximum of 5 characters n Read codes can be one to five characters long

Maximum of 5 characters n Read codes can be one to five characters long n The more characters, the greater level of detail in the code n Referred to as “ 5 -Byte” read codes n Users may have noticed some read codes followed by a “-0”, “ 1”, or “-2” etc n n 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 n n Preferred terms are the main descriptions Synonymous terms

Preferred and Synonymous Terms n n Preferred terms are the main descriptions Synonymous terms are alternate descriptions of the Preferred term Example: Acute MI Attack – Heart Coronary Thrombosis Heart Attack G 30 -1 G 30 -2 G 30 -4 P S S S 15

How to select the ‘right’ Read Code Direct code entry n n Entering the

How to select the ‘right’ Read Code Direct code entry n n Entering the code itself if it is known (e. g. C 10 for Diabetes) Accurate and quick – if you know the code! Searching by keyword n n n Entering the full term, first few letters, or abbreviation (e. g. diabetes mellitus, 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 n n 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 n Allows quick and standard data entry 16

Templates/Guidelines n n For routine data entry, templates can be very useful to: n

Templates/Guidelines n n For routine data entry, templates can be very useful to: n Speed data entry n Ensure that all appropriate information about a patient is obtained (especially useful in clinic environment) n Ensure that patient information is recorded consistently across the practice However… n No use for non-routine data entry n Limited to a pre-defined list of read codes n 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

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 allow. Medication 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) – H 33 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 Otherapeutic 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 – 8 CE 2 8 . d Central Suspected asthma – Nervous System Mental disorders. e Drugs used in Infections 1 J 70 Seen in Asthma Clinic – 9 N 1 d 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 chapter Injury & poisoning on the context. q Incontinence depending from appliances which the Causes injury & poisoning. s Stoma appliances information originates. 18

Useful Read Code Abbreviations O/E C/O H/O FH NOS OS NFQ HFQ NEC NOC

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 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 n n Without an understanding of Read Codes it is very easy

Common Errors n n 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

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 . g Obs, gynae, UTI 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 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 C 10 – Diabetes. e Drugs used in Infections Mellitus. f Endocrine drugs J Respiratory System. Recording. h Example: . k Eye of making this sort ofcutaneous mistaketissue are serious. M Skin / sub. 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, Otherapeutic 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

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 Otherapeutic 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 A 37 – 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

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 14 Y 1 – 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 Endocrine drugs Respiratory System – Forceps. h L 395 Chemotherapy etc J Digestive System ii delivery Haemotology / dietetic 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 Otherapeutic procedures Born by Forceps Administration (For 9 the Child) H Drugs used in Infections Obs, gynae, UTI Operations, procedures, sites Circulatory System Central Nervous System . g Laboratory procedures G Respiratory delivery T Musculoskeletal (For the Mother) Eye 23

Common Errors 4 Processes of Care Diagnoses Medication 0 A ‘a Gastro-intestinal . b

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 records. D (and. Diseases vice versa) of the blood Examinations & Signs 7 C 110 – 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 61 G – 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 Otherapeutic 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. o. Woman) 24

Common Errors cont’d n Using a diagnosis code to record that a patient does

Common Errors cont’d n 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: C 10 n Diabetes Mellitus Not present Using the text box to record data that should be separately read coded Example: 137 R Current smoker Advised patient to stop smoking instead of: 137 R Current smoker 8 CAL Smoking cessation advice 25

Common Errors cont’d These examples are bad practice because: n codes have been used

Common Errors cont’d These examples are bad practice because: n codes have been used in the wrong context and imply a different meaning n as far as the clinical system is concerned, whatever is typed in free text does not affect the application of the read code n n 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, e. GFR) and so record is incomplete 26

General Guidance on Read Codes n Understand the Read Code Structure and context of

General Guidance on Read Codes n Understand the Read Code Structure and context of codes when using them n Use Read Code guidance where available n Templates/Guidelines facilitate multiple data entries in a standard and quick way n Use diagnosis codes rather than H/O codes for current diagnoses n Don’t use a diagnosis code with free text to record a negative entry n Once a diagnosis code has been recorded, use a procedure code rather than the diagnosis code for future monitoring n Be as specific as you like when recording Read Codes, the structure allows this n Try not to use in-house created codes or synonymous terms 27

Recommendations for Practices n n n Staff Training Know your Read Codes Keep it

Recommendations for Practices n n n 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… n Understand the Read Code hierarchy n To build

The aims of this session… n Understand the Read Code hierarchy n To build confidence in using read codes n Find most appropriate read code n Know which codes to use for which purpose 29

Thank you for listening Any questions? 30

Thank you for listening Any questions? 30