Using the Read Dictionary

Introduction

Most clinical data is entered and stored as Read terms from the Read dictionary, not only in Medical History but for other structured data, for example, contraception data, test results. Even immunisations which are not selected from the Read dictionary are stored as Read terms.

Note - In April 2018, NHS Digital released the final update to the Read dictionary with a view for all care settings to be accessing the same clinical coding system, SNOMED CT. For now, every clinical entry is automatically dual mapped, it is allocated a Read term and a SNOMED CT term, this results in minimal impact to your practice, see SNOMED CT for details.

Consultation Manager eases the selection of Read terms by encouraging the use of Management Plans, Summary Forms, Guidelines and Add screens where relevant Read terms are offered from picklists. If you are unsure of the structured data area, then use History Add and rely on the system placing the record correctly.

Once a consultation is started you can either:

  • Just begin typing a Read term straightaway (if set up to do so).

  • Type a code preceded by a # if you know it, for example, #H33 and press Enter.
  • Press <F3> in Read Select for selection from the full Read dictionary.

But, once a Read window displays, how do you know what to type in order to select a Read term?

You can select a Read terms by either using:

  • A keyword, which you either know or guess at, for example, type cough and press Enter, or
  • By typing a Read code, preceded by #, for example, #171, you can then look through the hierarchical list.

Alternatively, from Read select , press <F3> (function key) which takes you to the full Read Select screen.

SeeAdding Clinical Data , or Keywords and Read Dictionary Selection Screen for further details.

A subset of the Read dictionary can be made into a practice formulary, with the commonly used Read terms (see Read formulary). Further additions can be made to the Formulary at any time.

Entries from Read chapters are colour coded allowing you, on the Patient Records screen and timeline, to quickly see problems that are related, the colours are practice definable.

See Consultation Manager Setup - Patient Record for details.

To check the version of Read dictionary installed:

  • From Consultation Manager, select Help - About Consultation Manager, or

  • From the Vision 3 front screen, select Help - About Vision, and check under installations.