Summarising records


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Standard current problem headings
  • .68P Adult screening: prevention data including screening BP.
  • .65 Vaccinations: all immunisations.
  • .685 Cervical neoplasia screening : all smear information.
  • .64 Child health care : all developmental assessment information.
  • .61 Contraception: all information relating to contraception.
  • .62 Pregnancy care: all information relating to current pregnancy.
Examples of commonly used default current problem headings
  • .G3 Ischaemic heart disease : includes angina, MI etc.
  • .G6 Cerebrovascular disease : all strokes, tia’s etc. Subarachnoid haemorrhage should not be coded under.G6 but coded as a separate current problem.
  • .G2 Hypertensive disease : all patients with hypertension.
  • .C10 Diabetes mellitus : all patients with diabetes.
  • .H33 Asthma: all patients with asthma.
Hypothyroidism Add last TFT recorded.
Diabetes Add next HbA1c and next annual review reminders.
Adult vaccinations Add appropriate vaccinations with date given.
Children To Anne for addition of developmental assessment and immunisation codes.
Women 20-65 To Anne for smear coding.

All important events should be recorded on the computer, taking care withchronic disease codes eg aspirin and cholesterol for patients with IHD. Allrelevant codes are automatically entered on the summary page.

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