Abbreviations Used for Read Selection
An abbreviation such as COPAIN takes you direct to D13. C/O: a pain BACKNAD will take you "2H81. O/E - spine NAD". These frequently use the combination of a Prefix and then a location or symptom. Negative examination findings are all coded with a prefix of "0" (zero).
ABBREVIATN Read CODE 1 Administration
ABDONAD 2516.00 Abdomen examined - NAD
ABDOPAIN 1969.00 Abdominal pain
ACB N217300 Achilles bursitis
ACT N217400 Achilles tendinitis
ADMITENT 8H29.00 Admit ENT emergency
ADVCIGS 6791.00 Health ed. - smoking
ANGNA G33..00 Angina pectoris
APPETN 1611.00 Appetite normal
APPX J2...00 Appendicitis and other disorders of the appendix
ARC N211z11 Painful arc syndrome
ASMA H33..00 Asthma
ASPJT 7K6Z000 Aspiration of joint
AUDIONAD 3133.12 Audiogram normal
AXLN 2C35.00 O/E -axillary lymphadenopathy
BACKNAD 2H81.00 O/E - spine - NAD
BACKNIL 16C1.00 No backache
BF10D 6412.00 Breast fed at 10 days
BF6W 6422.00 Breast fed at 6 weeks
BRUISEFOOT SE42000 Contusion foot
BSNAD 25S1.00 O/E - bowel sounds normal
BSNIL 25S2.00 O/E - bowel sounds absent
CATRCT F46..00 Cataract
CHCK 6819.00 Screening - NAD
CHR 9346.00 Total notes on computer
CLNSC 771J.11 Diagnostic colonoscopy
CNJCT F4C0.00 Acute conjunctivitis
COLUMP R022200 [D]Lump localized and superficial
COMREC 9ND6.00 Communication from:
COPAIN 1D13.00 C/O: a pain
CORASH 1D14.00 C/O: a rash
CVSNAD 2415.00 CVS examined - NAD
CX 44P..00 Serum cholesterol
DEATHFATHE 13M7.00 Death of father
DIEDHOSP 8HG..00 Died in hospital
DIETDM 8CA4100 Pt advised re diabetic diet
DISCHDC 8HE3.00 Discharged from day-case care
DISLOCSH S41..00 Dislocation or subluxation of shoulder
DNBATHING 8C19.00 Nursing care - bathing patient
DNV 9NFA.00 District nurse visit
DYSNIL 1A51.00 No genitourinary pain
EAR1 1C32.00 Unilateral earache
EAR2 1C33.00 Bilateral earache
ECZM M111.00 Atopic dermatitis/eczema
EMUNEG 4652.00 Urine pregnancy test negative
EMUPOS 4654.00 Urine pregnancy test positive
ENTNAD 2D12.00 ENT examination - NAD
EPGS 1972.00 Epigastric pain
EXCNAIL 7G32400 Total excision of nail
EYENAD 22E1.00 O/E - eyes - NAD
FBEYE SG0..00 Foreign body on external eye
FHASTHMA 12D2.00 FH: Asthma
FLL TC...11 Fall - accidental
FNDI 3128.00 Fundoscopy
FOETNIL 2571.00 O/E - breath smell normal
FRACTANKL S342000 Closed fracture ankle lateral malleolus low
FRIT 1B1H.00 Frightened
GANGWRIST N224500 Ganglion of wrist
GLUC1 4664.00 Urine glucose test = +
HAEMREC 9ND1.00 Haematology result received
HB 423..11 Hb estimation
HISTNAD 4K13.00 Histology normal
HYF H170.11 Hay fever - pollens
IMINJ 7L18.00 Intramuscular injection
IMPR 2126.00 Patient's condition improved
IMPRV 2126.00 Patient's condition improved
INFEYE F4C0.00 Acute conjunctivitis
INJJT 7K6Z200 Injection of therapeutic substance into joint
INJURYELBO SD3y000 Superficial injury of elbow NOS
INJVV 7A68.00 Injection into varicose vein of leg
INSRECEIV 9EW..00 Insurance form received
IPREC 9ND8.00 I/patient disch summary rec'vd
IUCDFIT 6151.00 IUD fitted
JOINTNAD 2H21.00 O/E - no joint abnormality
KNEEABN 2H29.00 O/E - knee joint abnormal
KWIRE 7K1PD00 Removal of Kirschner wire internal bone fixator
LABABN 419..00 Lab. test result abnormal
LABAWAITED 417..00 Lab. test result not back yet
LABNAD 418..00 Lab. test result normal
LABPHONE 41C2.00 Test result to pat.by 'phone
LABREC 9ND3.00 Microbiology report received
LACKNEE SA10000 Open wound of knee
LEAVINGYGP 9221.00 Patient says leaving list
LEFT 13VA.00 Left handed
LETREC 9ND5.00 Consultant letter from:
LETTAWAIT 9NG..00 Letter/report awaited
LETTERPAT 9NC3.00 Letter sent to patient
LETTFROM 9N36.00 Letter from specialist
LETTOPAT 9NC3.00 Letter sent to patient
LETTREC 9N36.00 Letter from specialist
LIFECOMPL 9E51.00 Life ass.exam.completed
LIVERNIL 25G1.00 O/E - liver not palpable
LNCERV 2C32.00 O/E -cervical lymphadenopathy
LNNAD 2C31.00 O/E - no lymphadenopathy
LOOSEKNEE N073.00 Loose body in knee
LOSSSIGHT 1B75.00 Loss of vision
LUMPBREAST 1A8..00 Breast lump symptom
MANIPLUMB 7J48H00 Manipulation of lumbar spine
MEDRED 8B3A200 Medication decreased
MGRNE F26..00 Migraine
MICTOK 1A11.00 Micturition frequency normal
MRINAD 5692.00 Nuclear magn reson normal
MSINCIS 9879.00 Minor surgery done - incision
MSS R065A00 [D]Musculoskeletal chest pain
MSUREQ 4615.00 MSU sent to lab.
MULTSYMPT 16...13 Multiple symptoms
NASALSYMP 1C8..11 Nasal symptoms
NECKOK 16A1.00 No stiff neck
NEWDONE 68R2.00 New patient screen done
NEWLET1 9OW4.00 New patient screen 1st letter
NEX 211..00 Patient not examined
NGBREAST B34..00 Malignant neoplasm of female breast
NOTIFJAUND 65V3.00 Notification of inf. jaundice
OAHIP N053512 Hip osteoarthitis NOS
OEX F501.00 Infective otitis externa
OKPAT 8C90.00 Patient reassured
OPMESH 7H11111 Primary mesh repair of inguinal hernia
OTC 8CA3.00 Patient advised re OTC medicat
PAINANK N245.11 Ankle pain
PBPOS 43A2.00 Inf mononucleos test positive
PERLA 2BI1.00 O/E - pupil reactions normal
PHNIL 14Z1.00 No relevant past medical hist.
PHYSPELVIC 8E77.00 Pelvic floor exercises
PMHBELLS 1476.00 H/O: Bell's palsy
PNDNIL 1731.00 No breathlessness
POSTOP 89Z..00 Pre/post-operrative proced.NOS
PPL 24F..00 O/E - peripheral pulses L.leg
PPR 24E..00 O/E - peripheral pulses R.-leg
PRGNT 62...00 Patient pregnant
PRNAD 25Q1.00 O/E - rectal examination - NAD
RASHNIL 2F12.00 O/E - skin examined - NAD
REBOUNDNIL 25E1.00 O/E - no rebound tenderness
RECSSD 9NDA.00 Report received from social services
REDTM 2D95.00 O/E - tympanic membrane red
REFCPN 8H7B.00 Refer to community psych.nurse
REFUSEMEAL 8I52.00 Refuses meals on wheels
REMSUT 7G22.12 Removal of suture of skin
REQHEPA 65W4.00 Requires a hepatitis A vaccination
REQVASECT 8M00.00 Vasectomy requested
RIGHT 13V9.00 Right handed
RISKWEIL 65PC.11 Weil's disease risk exposure
ROMRED 2H43.00 O/E - reduced joint movement
RSNAD 2315.00 Resp. system examined - NAD
RTEYE 2B6..00 O/E - visual acuity R-eye
RV 6A...00 Patient reviewed
SBCHEST 9N1b.00 Seen in chest clinic
SC1 9DC..00 SC1 - self certificate admin.
SCREENNAD 6819.00 Screening - NAD
SELFRX 8B3B.00 Patient on self-medication
SKINNAD 2F12.00 O/E - skin examined - NAD
SLROK 2H91.00 O/E - SLR normal - left=right
SOANIL 1831.00 No oedema present
SOBLYING 1735.00 Breathless - lying flat
SOBMILD 1733.00 Breathless - mild exertion
SOBMOD 1732.00 Breathless - moderate exertion
SOBNAD 1731.00 No breathlessness
SORETONGUE 1929.00 Tongue symptoms
SPINEABN 2H84.00 O/E - lumbar spine abnormal
SPUTNIL 1712.00 Dry cough
SRT 1C9..00 Sore throat symptom
STEAM 8762.00 Inhalation therapy
STRESSHOME 13HT100 Stress at home
STRESSWORK 13JM.13 Stress at work
SWNIL 2H31.00 O/E - joint not swollen
SXR 524..00 Plain X-ray skull
TANDA 7530600 Tonsillectomy and adenoidectomy
TEMPNIL 2E31.00 O/E - temperature normal
TENDFRONT 2DA3.00 O/E - frontal sinus tenderness
TENS 8643.00 Transcutaneous nerve stimulatn
TESTNAD 418..00 Lab. test result normal
THRNAD 2D15.00 Throat examination - normal
TNT F583.00 Tinnitus
TRB N215700 Trochanteric bursitis
TYMPNAD 3139.00 Tympanogram normal
UGSNAD 1A51.00 No genitourinary pain
USSLIVER 585A.00 U-S liver scan
VAGD 1A7..00 Vaginal discharge symptom
VAL 2B7..00 O/E - visual acuity L-eye
VAR 2B6..00 O/E - visual acuity R-eye
VASECTPART 6124.00 Partner had vasectomy
VDNIL 1A71.00 Vaginal discharge absent
VENAD 2681.00 O/E - bi-manual VE - NAD
VIRILL A79z.00 Viral infection NOS
VISIONOK 668A.00 Normal vision
WLL 1Y...00 Patient feels well
WLOPD 9R52.00 Patient awaiting OPD appt.
WT 22A..00 O/E - weight
WTISQ 1621.00 Weight steady
WX F504.11 Wax in ear
XPL ZV65411 [V]Explanation of medication
XRREC 9ND4.00 X-ray report received
XSTHIRST 1644.00 Excessive thirst
