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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.

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Using Keywords to find Read Codes

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  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

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