The structure of READ codes allows almost anything to be coded in the computer record. It does mean, however, that we must be rigid about our coding structure to allow complete and accurate database search results.
Accurate Read coding is important. Be aware of the difference between coding symptoms and diagnoses. It is vital that the meaning of the Read code is not changed: coding “Myocardial infarction” and then adding “excluded” as free text changes the meaning of the Read code and has significant implications for the practice QoF score!
The record should be coded according to the following structure
|Medication||Chapters a to s|
- Note that READ codes are case sensitive (ie “a” is NOT the same as “A”)
- For “working” diagnoses when a definitive diagnosis is not yet established, use chapter R (symptoms signs and ill-defined conditions) rather than chapter 1 (chapter 1 should only be used for describing symptoms, whereas chapter R should be used for working diagnoses.
|OS||Other specified:||Only use when a definitive code is not available (rare!).|
|NOS||Not otherwise specified:||Only use when a definitive code is not available (rare!).|
|EC||Elsewhere classified:||Classified elsewhere in code, usually referring to an underlying cause of a particular disorder.|
|NEC||Not elsewhere classified:||No matching subclassification|
|SO||Site of:||For determining the site of an operation.|
|D||Diagnosis:||Chapter R codes for working diagnoses when a specific diagnosis is not yet ascertained.|
|M||Morphology of neoplasms:||Subchapter BB of READ codes.|
|V||Supplementary factors influencing health status, but not including illness:||e.g. “normal pregnancy”.|
You do not need to learn codes to use the Read code system (although it can sometimes make it quicker to use). Type in the term which you wish to code, and use the pick lists to focus in further. How quickly you reach your desired term depends on what you type eg: for acute frontal sinusitis, you will get the appropriate term more quickly by typing front than acute. Typing the first 3letters often gives the quickest results.
READ code chapter headings