You can decide exactly which groups of codes,
and which specific codes you wish to use. It may be a good idea to browse
the Read code system and draw up a similar tree to work on, with as many
hierarchical levels as you need, but making the bottom level
You could then go on and do a similar thing
for respiratory, GI, URTIs, Items of service codes, or whatever you like!
The technical bit - getting it on the system!
This may seem a bit complicated at first, but
if you follow the instructions, it should be clear what to do. Setting up
your own coding tree is not difficult, but it is repetitive. If you do not
wish to do this yourself but would like to see what this is like set up,
speak to me, and I will see if I can help.
Firstly we are going to create an entry in
the access screen:
Go to the main menu:
Type DT for Dictionaries and Templates
Type C for Codes Templates and
Type E for Edit Access
We are now at the "Editing access
classification" screen. (Top, highlit bar)
(For your information...
All the following screens work on the same
principle. To make a new entry, you first have to press
"1". This allows you to choose an empty line, or to overwrite an
existing entry on a line. You are then able to choose the name of your new
entry. Once made, you highlight this entry to start creating new groups
which are subsets of it.)
So, lets make a new entry which will hold the
coding tree. Entries have to be existing Read Codes.
The system asks you to "select the line
label to add to or edit"
Choose an empty line, by typing in the
letter to the left of it.
At "select entry in the usual
manner", type in "Read Code" and press return.
You should get a couple of entries called
"Read Code Administration" or similar.
Highlight one of these, and press
return. You may be shown a second page, choose any code that has Read Code
administration in it. (This is just the title of your coding tree)
You are now presented with a group of
"H if this is entry is simply a
pointer to a lower hierarchical level in the access screen."
You will see that you are now back at the
access screen, but your "Read Code Administration" entry is in
place, at the point you chose.
So, we have the title, let’s start entering
some broad categories of your chosen codes.
Select your new code, "Read Code
administration" This takes you to a new, empty access screen.
Press 1 (as we are going to make
another new entry)
Pick your read code which is going to be the
pointer to the next level. In this case, it is Circulatory system diseases
G..., so, either follow down the full classification until you get to this
code, or type in "circ syst dis" and pick the option with
the code G.... This brings up all the subsets of circulatory system
diseases - all. I want the top level code itself, G.... Select
this, and press return.
Press H at the next screen, as this is
"simply a pointer to a lower hierarchical level".
Your new code is in place at A. We can now go
in and repeat this procedure again, to get our next level of choices.
Choose A ( your new code)
We get another blank screen.
Type in G2 ( the code for
Select Hypertensive disease - all G2
H this is a hierarchical pointer
Your new entry appears on the screen. The
next level is going to contain the actual codes.
Type G20 ( the code for essential
Choose Benign Essential hypertension
Choose C this is a CODE!
You will be back at the access screen, your
new code in position at A.
Type G24 (the code for secondary
Choose secondary hypertension - all
G24 (I don’t want a specific code in this group- it will actually give you
the choices you see under G24 in the patient's record)
This section is finished now. Press escape,
to go back a page, to get to hypertensive disease.
We are going to enter our next category, IHD
at this level.
Type G3 ( ischaemic heart disease) and
Choose G3 ischaemic heart disease all
Now back at the access screen again, choose
B, to start to build up the codes in this section.
You can either choose Angina
pectoris-all G33, (in which case you will be presented with the choices you
see now when you are using your tree in the patients record), or G33z angina
pectoris NOS, which is the bottom level code.
What ever you decide, choose C, this
is a code.
I am going to leave it here, as I hope you
now have the general idea about the setup of the coding system.
In summary, you can make as many levels of
detail as you like, by pressing 1 you make new entries, by selecting your
entries, you descend another level. Whatever you make as the bottom level
access screen entry, should be a code, as this is what will be presented to
you for recording in the patient's medical record. If you pick an
".....- all" code, then you will have a choice of the
"child" codes of the "all" code. If you pick a
"bottom level" code, then this is the code that will be inserted
into the patient's record.
Using the tree from the
Go into the patients record, MR, and
choose A Add any data. (Alternatively go to consultation mode, and
use problem title, or additional)
Press return for today
You will see your tree, "Read code
administration" at the access screen.
You only have one option so far, circulatory
system diseases. (However, by building up the formulary, you could have a
whole range of options, e.g. respiratory, GI, URTI, musculoskeletal
You have two options, hypertensive disease,
and ischaemic heart disease.
Select hypertensive disease
You have only two options, benign essential,
and secondary hypertension.
Select benign essential, and press return
You will need to press return a couple of
times and choose whether active or inactive to get back to the MR, where you
will see benign essential hypertension has been recorded, (or you will see
that benign essential hypertension has been recorded in the record in CM.)
Removing this coding tree
Choose the line on which you have entered
"Read code administration"
It will ask you if you wish to overwrite, say
yes. The tree will be removed.
Pressing F1 exit a couple of times will
return you to the main menu.
To transfer clinical data
from one code to another
The code DIABETES MONITORING ADMIN has been
entered in patients’ records in error, the correct Read code should be
DIABETES MELLITUS SCREENING.
1. set up a search for all patients with the
Read code 9OL DIABETES MONITORING ADMINISTRATION.
2. at the main menu select BD Batch
processing® Y to continue®
C Batch data alteration® select
Generated as result of search, select the relevant search name®
select A Clinical record® at the prompt
‘Identify the entry you are going to alter’, enter the code 9OL ®
at the prompt ‘Please replace the code to replace the above’ enter the
new code 6872 ® type in Y to accept the
alteration then Y again if absolutely sure.
3. all patients who had an entry of Diabetes
Monitoring Admin., Read code 9OL in the medical record will now display as
Read code 6872 Diabetes Mellitus screening