1 / 10

Using Keywords to find Read Codes

Using Vision – The Journal Tab. Using Keywords to find Read Codes. This is what you will learn. Using Keywords to find Read codes : Key words explained How they are used Examples of clinical acronyms Examples of clinical prefixes Finding a better Read code. Keywords explained.

fayre
Download Presentation

Using Keywords to find Read Codes

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Using Vision – The Journal Tab Using Keywords to find Read Codes

  2. This is what you will learn Using Keywords to find Read codes: • Key words explained • How they are used • Examples of clinical acronyms • Examples of clinical prefixes • Finding a better Read code

  3. Keywords explained • Short cuts to finding Read codes e.g. the keyword IHD will find Ischaemic Heart Disease • Not part of the Read code term • Based on commonly used medical abbreviations or logical prefixes • Keywords have no spaces e.g. painabdo

  4. What Vision displays Earache O/E - tympanic membrane red O/E - Rash absent Usual warning given What is typed Eara Tmred 0rash uwg How they are used This reduces the number of keystrokes

  5. Examples of clinical acronyms Type thisVision will give you TAHTotal abdominal hysterectomy NEC CABGSaphenous vein graft replacement of coronary artery DU Duodenal ulcer - (DU) AOM Acute non suppurative otitis media ECGStandard ECG IBIB113 DLS Incapacity for work form completed

  6. Examples of clinical prefixes -1 • The first part is the same and the second part is added without a space, for example: Rx finds codes related to medication RxStop: Treatment stopped - alternative therapy undertaken Medication stopped - contra-indication Drug not taken - pat disbelief Medication stopped - ineffective Press the down arrow to scroll through  these terms

  7. Examples of clinical prefixes -2 Other examples • FU finds codes related to Follow-up • FU1m – Follow-up 1 month • FU1w - Follow-up 1 week • FU2w - Follow-up 2 weeks • FUrefer - Referral needed • PMH finds past medical history • pmhIHD - H/O angina pectoris • pmhDep - H/O: psychiatric disorder

  8. Finding a better Read code - 1 You’ve found a Read code that’s nearly correct … e.g. Rxstop findsTreatment stopped - alternative therapy undertaken However…. the real reason is that they found the tablet too big With the ‘wrong’ code still displayed, press [F3] in the Read term entry field

  9. Finding a better Read code - 2 F3 will show you what you searched on You are looking in the formulary A list of other similar codes is displayed If not accurate enough…

  10. Finding a better Read code - 3 Click here to go into Read hierarchy Here are two better options Double click one to select

More Related