Read Code Abbreviations
Some common clinical abbreviations seen in Read descriptions are:
- O/E On Examination
- C/O Complaining of
- H/O History of
- FH: Family History
Other abbreviations appearing in the preferred terms are:
- OS Other specified - this options appears at the end of a list and should be selected if enough details is known about the data being recorded to say that it is not one of the other specific options.
- NOS Not otherwise specified - this option appears at the end of a list of entities and should be selected if not enough detail is known about the data being recorded to choose one of the other, 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.
- EC Elsewhere classified - This refers to an entity that is classified elsewhere in the codes. It is usually referring to the underlying cause of the particular disorder and it a hint that you may wish to code this case as a second code to make is more specific.
- NEC Not elsewhere classified - This means that specific varieties of this entity appear elsewhere in the codes; these will usually be shown on the picking list after a key term search. If none of the other match the concept to be coded, use this code.
- [SO] Site of - occurs in sub-chapter 7N, sites of operation. These equate with Chapter Z in OPCS4 codes.
- [D] Diagnosis - in Chapter R, for a working diagnosis, for example, [D] headache, [D] dizziness.
- [M] Morphology of neoplasms - chapter BB, recording cell type, for example, Transitional Cell Ca Bladder.
- [V] Correspond to the ICD-9 chapter that allows the recording of supplementary factors influencing health status or contact with health services other than for illness, for example, chapter ZV
- [Q] Qualifier (in preparation for Read 3, which moves away from rigid hierarchical relationship concept and allows cross-linking between codes (Chapter Z).
- [X] Cross referenced to specific ICD-10 codes (Read 2 relates to ICD-9).
