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{\title For the second half of the HDR on 16th October we will be considering the use of Read codes in record keeping and the problems}{\author Chris}{\operator Chris}{\creatim\yr2008\mo10\dy11\hr21\min33}{\revtim\yr2008\mo10\dy11\hr21\min50}{\version6}
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\par 
\par 
\par Read codes, the antidote to narrative medicine.
\par }{
\par For the second half of the HDR on 16}{\super th}{ October we will be considering the use of Read codes in record keeping and the problems of summaries. There are two main tasks to do before the session please come prepared having done one or both.
\par 
\par On the next page are parts of the medical history of three fictitious patients. There are no tricks, I may have made some errors with dates but the conditions have been chosen to illustrate some dilemmas in Read coding and constructing summaries. 
\par 
\par If you are in general practice or otherwise have access to a cl
inical system please choose and record for the session how you would read code these histories. If you are able, the gold standard would be to recreate them as fictitious patients and print your efforts off, otherwise just write the code and the rubric (t
he wording read codes use) down against the condition. If any of you are working in casualty consider how the casualty attendances would be coded.
\par 
\par Everyone should consider which entries should be flagged as summary items.
\par 
\par If you are unable to access a Read coding system or browser then your task is to consider the proposed Summary Care Record and }{\lang9\langfe1033\langnp9 NHS Care Records. As well as reading NHS Connecting for Health\rquote 
s take on this please look futher afield for ideas and views. For example the BMA, The Guardian, BBC, Information Commissioners Office, Pulse, Dr Rant and campaigning organisations have all published on this.
\par 
\par If like me you find 10 minutes a rediculous length of time for a consultation I would be interested in anecdotes about bizarre Read codes and how you used them.
\par 
\par 
\par Chris Oates.
\par \page }{Jim Bloggs 1/10/56 
\par 
\par 1 7 1960 T&A\rquote s
\par 1962 Acute Rheumatism
\par 1 8 64\tab Chickenpox
\par 23 2 1966 Greenstick fracture radius and ulna
\par 8 3 76 Admitted for observation, drunk and overdose
\par 1977 Alcohol induced psychosis
\par 1979 Admitted with abdominal pain had appendicetomy.
\par 1983 Divorced
\par 1996 Gastroscopy minimal gastritis
\par 1996 Started on beta blockers as bp raised
\par 1998 Gastroscopy normal
\par 2002 Admitted with Chest pain, ecg normal, continues with chest pain, coronary angiography normal. Upper GI endoscopy shows some minor oesophagitis.
\par 2006 BMI recorded as 32.
\par 2006 Started on metformin for diabetes
\par 2007 given sildenafil for erectile dysfunction.
\par 
\par 
\par Jane Smith 1 7 1982
\par 
\par 1 7 82 Delivered by emergency caesarean section
\par 14 1 84 Admitted with gastroenteritis iv rehydration
\par 1985 Asthma treated with salbutamol.
\par 17 6 86 Rash with amoxicillin given for otitis media
\par 1995 Casualty computer generated letter reports anaphylaxis treated with antihistamine.
\par 31 6 1997 Given cocp by family planning clinic.
\par 2002 Termination of pregnancy
\par 2003 Attends tired all the time, simple investigations normal, not a long term problem.
\par 2004 Seen several times by gp over 6 months after split from long term boyfriend and being sacked from work for poor attendance given citalopram, provided with sick notes and advised by CPN.
\par 2006 RTA, fractured right femur, full recovery, tetanus booster in casualty.
\par 23 12 2007 Positive pregnancy test, lmp 12 11 2007.
\par 20 8 2008 Normal delivery.
\par 
\par 
\par Alice Watts 21 5 1932
\par 
\par 1952 Delivered
\par 1954 Delivered boy
\par 1958 Miscarriage,
\par 1961 Positive pregnancy test, booked for delivery
\par 1964 Normal delivery
\par 1966 Sterilization
\par 1970 D&C for menorrhagia
\par 1972 Abdominal hysterectomy
\par 1996 Osteoarthritis knees and hips
\par 2002 Left hip replacement
\par 2003 Left cataract noted by optician
\par 2004 Left cataract extraction
\par 2005 Slips on a piece of fish on road outside Carrick\rquote s stall on Northallerton market and bruises left wrist. 
\par 2006 Ovarian serous tumour.
\par 
\par }}