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Book Contents

Book Index

Review

  • Diabetic Annual Check - The default Read code is 66AS Diabetic annual review. The Type of Program can be Hospital, Practice or Shared. Check Up options are: None, Acute, Annual, Routine. Also an entry on the Diabetes Summary Form and Data Grid..
  • Diabetic Consultation - The default Read code is 9OL Diabetes monitoring admin. If Seen by is left blank, this defaults to the Clinician making the entry; otherwise, click and select the GP. Also an entry on the Diabetes Summary Form and Data Grid..
  • Diabetic - Concerns - Use the free text Notes box for any comments about concerns. Entry of a Read code is optional. Also an entry on the Diabetes Summary Form and Data Grid..
  • Weight, BP: Any records which have already been made for Weight, and Blood Pressure will be displayed. Click with the right mouse button while pointing to these prompts and select Add for new entries.
  • Smoking - Any smoking entries are shown.
  • Foot Pulses (R leg and L leg) - The foot pulses are headed with R dorsalis pedis, R post tibialis, L dorsalis pedis and L post tibialis:
  • 246EA O/E - absent right foot pulses
  • 24EB O/E - right foot pulses present
  • 24EC O/E - Right dorsalis pedis abnormal
  • 24ED O/E - Right posterior tibial pulse abnormal
  • 24EZ O/E - R.leg pulses NOS
  • 24E1 O/E - R.leg pulses all present (default for R dorsalis pedis, or Foot Putlse Right Leg)
  • 24FA O/E - Absent left foot pulses
  • 24FB O/E - Left foot pulses present
  • 24FC O/E - left dorsalis pedis abnormal
  • 24FD O/E - Left posterior tibial pulse abnormal
  • 24FZ O/E - L.leg pulses NOS
  • 24F1 O/E - L.leg pulses all present (default for Foot Pulses Left Leg)
  • Ankle Neuropathy - The default Read code is 29H1 O/E - vibration sense normal. There are several other options: 29H O/E - vibration sense (up to 29HZ), 2A4 O/E - ankle reflex (old Read code default) - 2A4Z.

    Having selected the Read code, then select Left jerk/ Right jerk / Left ankle vibration sense / Right ankle vibration sense with one of the following qualifiers: Normal (the default), None, Absent, diminished, increased, Not examined.

  • Tactile sensation - TheRead code default is 29B1 O/E - tactile sensation normal. There are a number of other options on the picklist including: 29B O/E - tactilesensation, 311A Monofilament foot sensation test. Having selected the Read code, then select Left jerk/ Right jerk / Left ankle vibration sense / Right ankle vibration sense with one of the following qualifiers: Normal (the default), None, Absent, diminished, increased, Not examined.
  • 29B O/E - tactile sensation
  • 29B..11 O/E - touch sensation
  • 29B1 O/E - tactile sensation normal (Read code default on Tactile Sensation Add)
  • 29B2 O/E - anaesthesia present
  • 29B2.11 O/E - loss of touch sensation
  • 29B20 O/E - anaesthesia in legs
  • 29B21 O/E - anaesthesia of extremities
  • 29B3 O/E - hypoaesthesia present
  • 29B4 O/E - hyperaesthesia present
  • 29B4.11 O/E - hyperalgesia present
  • 29B5 O/E - paraesthesia present
  • 29B50 O/E - paraesthesia in hands
  • 29B6 Hemisensory loss
  • 29B7 10g monofilament sensation present
  • 29B8 10g monofilament sensation absent
  • 29B9 10g monofilament sensation R foot abnormal
  • 29BA 10g monofilament sensation L foot abnormal
  • 29BB 10g monofilament sensation R foot normal
  • 29BC 10g monofilament sensation L foot normal
  • 29BZ O/E - tactile sensation NOS
  • 311A Monofilament foot sensation test
  • Foot care - The default Read term is 2G5 O/E - foot to 2G6£ and also 66AE Feetexamination.
  • Fundoscopy (including laterality) - The default Read term is 3128 Fundoscopy, 2BA O/E - optic disc inspection (and hierarchical codes), and 2BB O/E - retinalinspection (and hierarchical codes.
  • Visual Acuity (R eye and L eye) - The default Read term for the right eye is 2B6 O/E - visual acuity R.-eye, and also includes 2B61 O/E - visual acuity R.-eye =6/5, 2B62 O/E - visual acuity R.-eye =6/6, 2B63 O/E - visual acuity R.-eye =6/9.

    For the left eye, it is 2B7 O/E - visual acuity L.-eye, and includes 2B71 O/E - visual acuity L.-eye =6/5, 2B72 O/E - visual acuity L.-eye =6/6, 2B73 O/E - visual acuity L.-eye =6/9.

  • Diabetic Retinopathy Screening - Note that the Diabetes Summary Form and Data Grid have an additional entry (not on the Diabetes Management Plan) for retinopathy including 68A7 Diabeticretinopathy screening* (default), 68A8 Digital retinal screening, 68A9 Diabetic retinopathy scr offer, 58C1Retinal photography*, 8HBD Retinopathy follow-up*, 8HBG Diabetic retinopathy 12 month review*, 8HBH Diabetic retinopathy 6 month review*, 8I3X Diabetic retinopathy screening refused*, 8I6F Diabetic retinopath screening not indicated* (* QMAS code).