|
|
|
|
|
Administration READ Terms
Here are some useful READ terms for non-clinical tasks and topics. Entries can be made either from History-Add or Record on the top of the MRO column, Patient Record, or from specific screens such as Referral-Add.
To select from READ, either use # followed by the code, eg, #9D11, or type in a READ term keyword - these are in italics below. Using the Easy-READ guideline is also a quick way of finding relevant READ terms (see under Local Guideline in Local Guidelines - Administration.
Advice
See Advice READ codes
Correspondence
See also Referrals - in particular Secretarial READ Codes for Referral Letters, and Clinical Correspondence
9N36 Letter from specialist (specialist)
9NC Letter sent to outside agency (letter)
Certificates / Reports.
9D Certificates (certificat)
9D1 Med3 - doctor's statement (med3)
9D11 Med3 issued to patient
9D2 MED5- doctor's special stat.(med5)
9D21 Med5 issued to patient
9D5 Private sickness certificate
9D6 Passport application signing (passport)
9D9 Jury exemption form (jury)
9DF Med4 Doctors statement (doctors)
9DF1 Med4 Doctors statement (doctors, med4, statement)
9E MedicalExaminations / Reports
9E1 Employment examination / reports (employment)
9ER Solicitor's report (solicitors)
9EU Mobility allowance claim rep. (mobility)
9EX Medical reports sent (sent)
9EY2 Attendance allowance form completed (attend, completed, form)
9EY3 Report to benefits agency (agency)
Death Administration
Encounters and Screening Administration (for example, Letters sent)
See also Encounter Information READ codes and Recalls
Asthma
9OJA Asthma monitoring check done
9N1d Seen in Asthma Clinic
Contraception
9N0U Seen in family planning clinic
9O9 IUCD follow up Admin (IUD, IUCD
9OB Oral Contraception Admin (oral)
Diabetes
6872 Diabetes mellitus screen (diabetes)
8H7f Referral to diabetic nurse (diabetes)
9N1Q Seen in diabetic clinic
9NM0 Attending diabetes clinic (diabetes)
9OL Diabetes monitoring admin.(diabetes)
Others
2125.11 NAD on examination (NAD)
6925.11 HGV - heavy good vehicle exam. (HGV)
69D2.14 Well man health examination (well)
69D2.16 Well woman health examination (well)
69G Private medical examination (private)
6A Patient reviewed (patient, reviewed)
8B314 Medication review (review)
8CB Had a chat to patient (chat)
8E Physiotherapy/remedial therapy
8HE Discharged from hospital (discharged)
8HJA.11 Casualty self-referral (casualty)
9EL..12 Taxi driver exam admin (taxi)
9N03 Seen in hypertension clinic (hypertensi, seen)
9N1A Seen in hospital out-pat (OP)
9N1U Seen in elderly assessment clinic (assessment, clinic, elderly, seen)
9N31 Telephone encounter (phone)
9N42 Did not attend - no reason
9N47 Appt cancelled by patient (appointme, cancelled, appt)
9N58 Emergency appointment (appointmen)
9N9 Ambulance request for patient (ambulance)
9NC Letter sent to outside agency (letter)
9NC1 Letter sent to consultant (consultant)
9NC2 Letter sent to solicitor (solicitor)
9OM Geriatric Monitoring Admin (geriatric
9ON Stress monitoring admin. (stress)
9OW New Patient Screen Admin (new, patient)
ZV67 [V] Follow-up examination
Smears
See also under Cervical Cytology - READ Codes for Smear Results
9O8 Cervical Smear Admin (cervical, smear)
Vaccs and Imms
9O7 Rubella Admin (rubella
9OX Influenza vacc.administration (influenza, vaccinatio)
ZV708 [V] Routine child health examination (child, health, routine)
Registration Details
These codes might be useful to add to a patient's PMA or New Registration report.
912C Patient registered by FPC
912A Patient allocated by FPC (allocated)
9R8 Date Records held from
Social / Personal History Details
132 Social Group (social) - Note: This could be used as alternative to recording specific occupation
134 Ethnic Origin (country, origin)
13J Employment Details (employment, milestones)
