Included to allow cross-referencing with ICD9/10 OCPS4

NOS Not otherwise specified
OS Other specified
OS – Otherwise specified (codes end with y) This option indicates that enough is known to say categorically that it is not one of the other options at this level.

NFQ: Not further qualified
HFQ: However further qualified
EC: Elsewhere classified. Usually refers to an underlying cause of a disorder
EC – Elsewhere classified – This abbreviation refers to an entity that is classified elsewhere in the codes. It is usually the underlying cause of the particular disorder and is a hint that you may wish to code this cause as a second code to make it more specific.
NEC: Not elsewhere classified This means that specific varieties of this entity appear elsewhere in the classification. These will usually be shown on the picking list after a term key search. If none of the other matches the concept to be coded, use this code.
NOC: Not otherwise classifiable
NFQ NOT FURTHER QUALIFIED
NOC – Not otherwise classified
NOS NOT OTHERWISE SPECIFIED This option appears at the end of a list of entities at a given level. It should be selected it not enough detail is known about the data being recorded to choose one of the more specific options. It means the same as recording the code one level higher, but may be useful if a more detailed cross-reference code needs to be generated. For example, the term “asthma” alone means the same as “asthma NOS”.

[SO]: “site of” codes equate to chapter “Z” in OPCS4 and provide a way of coding the site of operation as a subsidiary code. (These codes are in Version 25-byte only).

[D] “diagnosis”: This code are used when a clinician has a working diagnosis which may later be identified as a defined disease entity. For example, “chest pain” is a symptom that may become a firm diagnosis after investigation where no further cause is found; such codes are often used as a “diagnosis” when it is not possible to be more precise.

[M] “morphology of neoplasms”: Codes containing this symbol are for recording the cell type of the neoplasm, and correspond to the morphology chapters in the ICD classifications.

[V] Version 2 terms that have been derived from ICD9/10 .
[X] Version 2 terms that have been derived from ICD9/10

Other Useful Read Terminology
# Fracture.
A/R – Adverse reaction
[D] WORKING DIAGNOSIS Read Chapter R These codes are used when a
clinician has a working diagnosis which may later be identified as a defined disease entity. For example “dizziness” and “headache” are symptoms which may become a firm diagnosis after investigation but are often used as a “diagnosis” when it is not possible to be more precise.

FB – Foreign body
FH – Family History;
FH * Family History of malignancy
H/O – History of

[M] Morphology of neoplasms (e.g. Transitional Cell Ca Bladder) Read Chapter B.
Terms that contain this symbol are for recording the cell type of the neoplasm and correspond to the morphology chapters in the ICD classifications.

O/E – On examination

PH – Personal history of;
PH* Personal history of malignancy

[Q] Qualifier (Read 3 moves away from rigid hierarchical relationship concept and allows cross-linking between codes. Read Chapter Z.

[SO] SITE OF – Occurs in the sub-chapter &N… Codes with this included equate to chapter Z in OPCS4 and provide a way of coding the site of operation as a subsidiary code.

[V] Other factors affecting health – Occurs in sub-chapter ZV…Read Chapter Z. These codes correspond to the ICD10 chapter that records “supplementary factors influencing health status or contact with health services other than for illness” (for example “normal Pregnancy” ZV22 may affect the contact or health status other than illness).

[X] Derived from the ICD-10 updates. These use contemporary concepts and it is advised that these codes should be used for mental health and behavioural disorders (Eu replaced Chapter E) and for causes of morbidity/mortality (U replacing chapter T).

Notes summarising protocol (Trafford PCT)

Notes summarising protocol (Trafford PCT)

A summary is a record of important relevant aspects of patient’s life events, from birth to present day, from hospital discharge letters to GP records, and to provide a database of information on the computer, which in turn can help to improve patient care.

GUIDE TO SUMMARISING
1. All notes need to be weeded and tagged by the relevant staff and placed in chronological order before any summaries can be started.
Responsible staff: _________________________________________________________

2. A summary is to be entered onto the electronic summary.
Responsible staff: ________________________________________________________

3. Summaries can be undertaken by a trained member of staff eg: nurse/doctor/trained receptionist /trained administrators or medical assistants.
Identified staff trained in electronic summarisation / Read codes: _________________

4. Respect the patient’s privacy, do not discuss work outside this is highly confidential. Do not take patient notes off site for summarising. If a patient is known to the summariser, someone else should undertake the summarising
Confidentiality agreements signed by note summarisers: ________________________

5. Preserve integrity and be aware of accuracy of manual record only work with one patient’s notes at a time – do not overlap different sets of notes. Refile details in a chronological manner. Also, over time medical records can become wrongly filed etc. If incorrect information / information relating to another patient is identified, highlight to a supervising member of staff.

6. Access to notes is important. Notes may have more than one file (1st/2nd or fat files) so ensure all the notes are together for the relevant patient. If they are not available or are out for surgery they must be handed to the summariser before being filed away.

7. It is essential to have a link GP or be able to liaise with the Practice Manager / supervisor if there are any queries with the patient’s notes. This can happen if the notes are illegible, if there is a wrong entry, if information to verify the entry cannot be located etc. Summarisers should never assume anything if they are unsurethey should always check with the link GP.
Identified GP/s: __________________________________________________________
Supervisor for note summarising: ____________________________________________

8. When going through letters, results, smears etc. be aware of the date; use the clinic date not the actual date of letter.

9. The day/month/year of diagnosis / intervention is to be entered on the summary, if not found enter for day and for the month (01/01) followed by year.
Never electronically record H/O diagnosis (history of), always enter the diagnosis with the date of diagnosis (not today’s date) or NK(date not known) and enter H/O in text.

10. All hospital operations, admissions, procedures and results are to be entered.

11.Enter children who are “on the child protection register’ and enter when removed from the child protection register.

12. Enter the Family History if you know the exact details. The Practice Nurse may be able to get the full information required; this then can also be entered on the Family History TEMPLATE.

13.Enter all known allergies in summary and electronically on TEMPLATE.

14. Enter significant social circumstances eg:death of close relative etc.

15 .It is advisable to use some form of indicator either on the notes or on the Lloyd George to state that the summary has been completed.

16. It is essential that summaries are maintained by staff thereafter.

ELECTRONIC SUMMARIES and Read CODES
Read codes are used to electronically record medical diagnoses, investigations, interventions etc. These are nationally approved and developed by a GP (Dr Read).

17. Once the manual summary is complete they can then be entered electronically onto the computer by Read codes.

18.Appropriate and standardised Read codes must be used for the diagnosis / investigation / intervention entered. These will be used for searches for the new GMS contract Clinical Quality Indicators.

19. On completion of the electronic summary, enter the Read code for “logging off” to state that the” Note summary on computer” is 9344 You will be requested to record the name of the summariser.If updating then use 9348.

20. It is crucial that electronic records and summaries are maintained thereafter – this may be the responsibility of all staff or designate staff. Validation of disease registers is recommended at regular agreed intervals.

QOF Disease Registers
See latest QOF Clinical Indicators Businesss Rules for specifics that should be recorded for each disease area & related tests & results.
Diabetes
Stroke/TIA
Asthma
COPD
Epilepsy
Mental Health
Cancer
Hypothyroidism
CHD
Hypertension
Dementia
Depression
Learning Disability
Palliative Care
Obesity
AF
CKD
Ethnicity
Heart Failure

Summary of Treatment Card’ This list contains some of the main diagnoses and interventions to be entered, but liaise with the doctors to decide what actually needs to be included within the practice AND determine where to record eg significant active / past and minor active / past.
Hypertension
Asthma
CHD
COPD
Angina
MI
CCF / LVD
Bronchiectasis
Emphysema
Bronchitis
Atrial Fibrillation
Pneumonia
Valvular Heart Disease AS/MS
TB
SVT
CVA TIA
Allergies
Haemoglobinopathies
Significant Family History
Allergies
Epilepsy
Migraine
Learning Disabilities
Down’s Syndrome
Meningitis
Rheumatic fever
Panic Attacks
Chronic Fatigue Syndrome
Coeliac Disease
Diverticular Disease
Depression
Anxiety
Developmental delay
Crohn’s Disease
Partially sighted/Blind
Osteoarthritis
Rheumatoid Arthritis
Diagnostic Investigations eg ECG, Stress Test, Echo, CT Cholesterol, BS, HbA1c etc
Osteoporosis/Osteopenia
Agoraphobia
Psoriasis
Hyperthyroidism
Eczema/Dermatitis
Ulcerative colitis
Panic Attacks
Hearing impairment
Abortion
Manic depressive disorde
IBS
Schizophrenia/Paranoia
Cancer
Visual impairment
Overdose/suicide attempt/self harm
Diabetes Type I/II
Miscarriage
Hypothyroidism
TOP
Endometriosis
Multiple Sclerosis
MND
Infertility
Hepatitis ABC
MRSA
Renal Disease
CKD
Rhesus status
HIV
Jehovas Witness
Living Will
Transplants
RTA
Fractures
Congenital Disorders
Operations
Adoption Status

Notes Summarising Brief Procedure
Record all MAJOR DIAGNOSIS past or present including any chronic illness, that requires a referral to a hospital consultant and mental health disorders. The commencement date must be entered.
Record all FRACTURES , including site of fracture (in MINOR PAST)
Record all OPERATIONS and PROCEDURES that have taken place during their life.
Record all related ECGs; Echocardiograms; Heart Scans.
FEMALE PATIENTSrecord the following
PARITY STATUS
PREGNANCIES (and birth details)
MISCARRIAGES
TERMINATION OF PREGNANCIES
HRT
Enter the last recorded entry for each of the following (consider diagnostic tests)
BLOOD PRESSURE
SMEAR RESULT
MAMMOGRAM RESULT
SMOKING STATUS / ALCOHOL STATUS
TOTAL CHOLESTEROL
BLOOD GLUCOSE / HbA1c
SPIROMETRY
Enter any recorded FAMILY HISTORY (specifically if possible )
STROKE
DIABETES
CHD
ASTHMA
CANCER
Other Entries
ALLERGIES (record allergen)
IMMS FOR CHILDREN UNDER 16 and RECENT VACCS FOR OVER 16
RECALL DATES FOR NEW PT SCREEN AND SMEAR TESTS
IF CHILD ON CHILD PROTECTION REGISTER (removal from register should also be entered as a significant and active)
THERE IS NO NEED TO RECORD ALL MINOR COMPLAINTS THAT PATIENTS ATTEND SURGERY FOR ON A REGULAR BASIS EG: COLDS, FEVERS, RASHES, TONSILLITIS, BUMPS/SCRAPES, BRONCHITIS, TWISTS and SPRAINS ETC.

MAINTENANCE OF SUMMARISING
Unless stipulated otherwise, this will be maintained within the electronic patient record using the standardised, agreed Read codes should be used.

Any of the above items that the practice has agreed should be contained within a summary should be recorded by the clinician seeing the patient within a routine consultation or chronic disease monitoring. This may involve using a specific template within a clinical system. Alternatively, the clinician may highlight the information that needs to be recorded for a trained administrator who is familiar with Read codes to enter onto the computer.

The practice should have a system of highlighting any of the above diagnoses / investigations / interventions that are documented within hospital letters or test results. These should be entered onto the clinical system by either a clinician or administrator familiar with Read coding.

At regular agreed intervals (ideally once a year), disease registers should be validated by running searches on patients with specific agreed Read codes recorded against relevant medication searches.
A suggested process for validation can be obtained from the Prescribing Team at Trafford PCT on 873 9525.

Key aspects of QuIP DES as laid out in the specification are:
It is a plan agreed by the PCT and contractor
It must include a protocol for how the summarsising is to be done and arrangements for ongoing maintenance. Non-medical personnel must
a. be fully trained,
b. not take medical records away from the premises,
c. have appropriate access to GP performers when they have queries,
d. sign a confidentiality agreement,
e. be appropriately supervised

You should use the codes
9348: Computer summary updated
9344: Note summary on computer

Note summarising with eye on QOF