- Effective use of Read Codes -

1. 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. 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 understandingRead 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)

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. 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 667 Epilepsy monitoring 663 Respiratory disease 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. 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. 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 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) O/E C/O H/O FH NOS OS NFQ HFQ NEC NOC [SO] [D] [M] [V] [X]

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 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 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 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 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 MellitusNot 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?