David Jobson wrote:
> From: "Geoff Schrecker" <[log in to unmask]>
>
>>> About to start summerising 500 sets of notes from scratch. Any hints
>>> tips or links to sites that have Read codes as we have no computer
>>> system yet. :(
>>
>> http://www.liverpool-ha.org.uk/health/read/fivefigcode.htm
>>
>> http://www.ceppc.org/scimp/readCodes.shtml#1
>>
>>
>
> But sadly these are not full 5 byte lists
You really don't want the whole list of 5 byte codes, it's overwhelming
and unnecessary.
I'd suggest you decide first of all what you want to achieve at both a
clinical and an administrative level from the summaries, and create them
on paper in the first instance. When we started on this exercise nearly
ten years ago, we wanted to create summaries which would simplify
referrals and insurance reports, and we combined opportunistic
summarising by doctors (when a referral or a report was necessary) with
systematic summaries generated by staff.
You then need to decide how precisely you need to code the summary
information to achieve the same purposes for the computerised summary
record. You'll see that the SCIMP set of codes is relatively small, but
includes the vast majority of important diagnoses for GPs' purposes. For
example, Read Code G30z. Myocardial Infarction (Acute) is the only one
listed for MI, although it is possible within the Read Codes to be much
more precise about the site of the infarction.
My personal view is that the coding should be as close to the diagnosis
as possible, so that in later exchanges of data between professionals
the Read Code is all that is necessary, but if you're new to this game
you might prefer to "Keep It Simple, Stupid". Remember that if you do
deliberately dumb down the diagnosis at coding time you may come to wish
you'd entered the more precise code at a later date. If you use the full
precision first time round you can always ignore the detail when
searching (e.g. for all patients who have had MIs in the last five
years) by using a parent code, which will identify all the children.
--
Michael
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