Coding procedures

 

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Read codes – structure and use

Asthma

Use the following codes

  • .H33 Asthma as the current problem for all patients with asthma. .
  • .6631 Initial resp. assessment
  • .6632 Follow-up resp. assessment
  • .H333 Acute exacerbation of asthma

If Asthma becomes dormant, insert the applies to date.Dormant asthma is defined as asthma with no attacks in thelast 12 months and no prescriptions for asthma treatment in thelast 12 months.

Breast screening mammography

  • Results are recorded under adult screening current problem.
  • Defaulters: add reminder .@!J7 X-ray due text mammogram for each patient.

Domestic violence

  • Record this using .SN56 Adult maltreatment syndrome or codes below this.

Usual health visitor

The child’s usual health visitor should be recorded as .6656 Shared care GP/HV with the name of the health visitor as free text under the current problem .64 Child health care.

Hypertension

Use the following codes

  • .G2 Hypertensive disease as the current problem for all patients with hypertension.
  • Coding hypertension
    • “Hypertension” if treated with pills
    • “Raised BP reading” if lifestyle changes only
    • If patient moves from rased BP to hypertension, relegate “Raised BP reading” into “Hypertension”
  • As a note under the above current problem, insert the appropriate read code eg:
    • .G201 benign essential hypertension.
    • .G24 secondary hypertension
  • Blood pressure readings O/E BP reading are inserted under the appropriate current problem ie: .G2 Hypertensive disease if patient has hypertension or .68P Adult screening if the patient does not.

Ischaemic heart disease

Use the following codes

  • .G3 Ischaemic heart disease as the current problem for all patients with ihd.
  • .G33 Angina pectoris if the patient has angina, under the above current heading.
  • .G58 Heart failure if the patient has heart failure, under the above current heading.
  • .12C2 Family history of ischaemic heart disease <60 if appropriate, under the above current heading.
  • .1226 No family history of ischaemic heart disease <60 if appropriate, under the above current heading.

Learning disabilities

  • Eu81z Developmental disorder of scholastic skills unspecified should be used.

Stroke

Use the following codes

  • .G6 Cerebrovascular disease as the current problem for all patients with stroke (do not use for subarachnoid haemorrhage).

Warfarin

  • .66Q Warfarin monitoring as a current problem.
  • .42QE INR should be under this current problem
  • Results of INR entered as numeric with dosage instructions as free text.
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