Introduction to Read Dictionary

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

Note - In April 2016, 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, codes are dual mapped into both the Read database and SNOMED resulting 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 can be selected from a picklist. If you are unsure of the structured data area, then use History Add and rely on the system placing the record correctly. Lists of Read terms are given within each category on the on-screen help sections.

• Once a consultation is started, you can just begin typing a Read term straightaway (if set up to do so).
• Or type a code preceded by a # if you know it, eg #H33 and press Enter;
• or press F3 in the Read Select window for selection from the full Read dictionary.
• On the History tab, a History-Add screen displays, with the cursor waiting at the Read select window.

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

Read terms can be selected either by means of keyword, which you either know or guess at, eg cough, and pressing Enter, or by typing a Read code, preceded by #171, eg . You can then look through the hierarchical list.

Alternatively, at a Read select window, just press <F3> (function key) which takes you to the full Read Select screen. See Quick add of Read descriptions from front - Add screen, or Keywords or Select by Code/Hierarchy on Read Dictionary screen .

A subset of the Read dictionary can be made into a practiceformulary, 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 which on the Patient Records screen and timeline means you can quickly see problems that are related. The colour coding is set in Consultation - Options - Setup (Patient Record Setup Options).

To check the versions of software your system is running:

1. From the Vision 3 front screen, select Help - About Vision, the screen displayed summarises which versions you are running of:

   • Vision 3

   • Vision+

   • Vision Apps

   • Gemscript Drug Dictionary

   • Read Dictionary

   • SNOMED

   • Supplementary

2. Select OK to exit.