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Using Vision – The Journal Tab. Using Keywords to find Read Codes. This is what you will learn. Using Keywords to find Read codes : Key words explained How they are used Examples of clinical acronyms Examples of clinical prefixes Finding a better Read code. Keywords explained.
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Using Vision – The Journal Tab Using Keywords to find Read Codes
This is what you will learn Using Keywords to find Read codes: • Key words explained • How they are used • Examples of clinical acronyms • Examples of clinical prefixes • Finding a better Read code
Keywords explained • Short cuts to finding Read codes e.g. the keyword IHD will find Ischaemic Heart Disease • Not part of the Read code term • Based on commonly used medical abbreviations or logical prefixes • Keywords have no spaces e.g. painabdo
What Vision displays Earache O/E - tympanic membrane red O/E - Rash absent Usual warning given What is typed Eara Tmred 0rash uwg How they are used This reduces the number of keystrokes
Examples of clinical acronyms Type thisVision will give you TAHTotal abdominal hysterectomy NEC CABGSaphenous vein graft replacement of coronary artery DU Duodenal ulcer - (DU) AOM Acute non suppurative otitis media ECGStandard ECG IBIB113 DLS Incapacity for work form completed
Examples of clinical prefixes -1 • The first part is the same and the second part is added without a space, for example: Rx finds codes related to medication RxStop: Treatment stopped - alternative therapy undertaken Medication stopped - contra-indication Drug not taken - pat disbelief Medication stopped - ineffective Press the down arrow to scroll through these terms
Examples of clinical prefixes -2 Other examples • FU finds codes related to Follow-up • FU1m – Follow-up 1 month • FU1w - Follow-up 1 week • FU2w - Follow-up 2 weeks • FUrefer - Referral needed • PMH finds past medical history • pmhIHD - H/O angina pectoris • pmhDep - H/O: psychiatric disorder
Finding a better Read code - 1 You’ve found a Read code that’s nearly correct … e.g. Rxstop findsTreatment stopped - alternative therapy undertaken However…. the real reason is that they found the tablet too big With the ‘wrong’ code still displayed, press [F3] in the Read term entry field
Finding a better Read code - 2 F3 will show you what you searched on You are looking in the formulary A list of other similar codes is displayed If not accurate enough…
Finding a better Read code - 3 Click here to go into Read hierarchy Here are two better options Double click one to select