Clinical coding is the translation of terminology used in healthcare into a coded form. It involves standardisation of the terms, and the placing of the codes in a structured hierarchy. Because healthcare is immensely complex, a system of codes where similar problems or treatments are grouped is required.

Clinical terminologies are comprehensive lists of terms used in the care, treatment and management of patients, which enable computer systems initially to store, and then to retrieve, patient information in a natural clinical language.

For the majority of GPs the most important use of clinical coding is in the creation of an electronic patient record (EPR).

Clinical terminologies used for this purpose have a multitude of functions. These include:

• Allowing the development of a computer system that uses clinical data
• Creating a standard language for use in healthcare computer systems
• Enabling clinical management based on collated patient data, i.e. clinical audit
• Enabling research.

Clinical terminologies support structured clinical information, which in turn can be searched or reported on by a computer.

A clinical record that is completely free text offers little advantage over a conventional written record. A clinical record with only coded entries, with no descriptive text, provides an incomplete clinical record. Clinicians need to strike a balance between the two.

Read Codes

Read Codes are a comprehensive list of clinical terms intended for use by healthcare professionals to describe the care and treatment given to patients. They include signs, symptoms, treatments, investigations, occupations, diagnoses and drugs and appliances.

This coding system was invented and developed in 1982 by a GP, Dr James Read, following the introduction of a GP-based computer system called Abies. Initially Read Codes were only used in general practice, but they have been significantly developed and improved over the years and are now used throughout the NHS.

In 1990, the NHS purchased the Read Codes from Dr James Read and made them the UK standard coding system for the NHS. The NHS then decided to expand the codes to cover all areas of clinical practice to include physiotherapy, nursing and health visiting, and commissioned the Clinical Terms Project.

Read Codes are currently the best coding system available to capture a complete medical record, which can be used for audit, analysis and research. They allow coding of all diagnoses, procedures, drugs and administration.

If anyone is concerned about the data their NHS records or coding used please contact the surgery to discuss further.