Vision 3 Read Dictionary Changes Q3 2014 Copyright © INPS Ltd 2014 The Bread Factory, 1A Broughton Street, Battersea, London, SW8 3QJ T: +44 (0) 207 501700 F:+44 (0) 207 5017100 W: www.inps.co.uk Copyright Notice © 2014 INPS All Rights Reserved. No part of this document may be photocopied, reproduced, stored in a retrieval system or transmitted in any form or by any means, whether electronic, mechanical, or otherwise, without the prior written permission of INPS. No warranty of accuracy is given concerning the contents of the information contained in this publication. To the extent permitted by law, no liability (including liability to any person by reason of negligence) will be accepted by INPS, its subsidiaries or employees for any direct or indirect loss or damage caused by omissions from or inaccuracies in this document. INPS reserves the right to change without notice the contents of this publication and the software to which it relates. Product and company names herein may be the trademarks of their respective owners. INPS Ltd. The Bread Factory 1a Broughton Street London SW8 3QJ Website: www.inps.co.uk Contents READ DICTIONARY CHANGES QUARTER 3 2014 1 Introduction Summary 1 1 Read Codes and Keywords Added for this Release 2 Read Codes Changes for this Release 24 Read Codes Deleted for this Release 24 Other Term Keys Added for this Release 25 Term Keys Changed for this Release 25 Term Keys Deleted for this Release 26 Synonym Keys Added for this Release 26 Synonym Keys Deleted for this Release 27 INDEX 29 iii Read Dictionary Changes Quarter 3 2014 Introduction This is the change report for the Quarter 3 2014 Medical Read Codes Release of the Read dictionary. Summary There were 659 Read codes added for this release. There were 13 Read codes changed for this release. There were 0 Read codes deleted for this release. There were 944 Term Keys added for this release. There were 5 Term Keys changed for this release. There were 4 Term Keys deleted for this release. Read Dictionary Changes Quarter 3 2014 1 Read Codes and Keywords Added for this Release Training Tip - Remember, to make it easier to find the Read codes you require, you can add your own Keyword to a Read code, please refer to Add New Keywords to Read codes http://www.inpshelp.co.uk/DLM470/Consultation_Manager/index.htm #25768 from the on-screen help for details. Read Code Read Term Keyword 0Z7.. Armed forces reservist RESERVIST ARMED 117.. No change in medical history HISTORY 122B1 No FH of breast cancer meeting NICE CG164 referral criteria 122Q. No family history of Parkinson's disease PARKINSON 12A5. FH: Retinitis pigmentosa RETINITIS PIGMENTOSA 133g. Family concern about patient CONCERN 133h. Friend concern about patient CONCERN FRIEND 13Ho. Witness to adult substance misuse WITNESS MISUSE 13Ho0 Witness to adult alcohol misuse MISUSE 13Hp. Witness to adult criminal activity WITNESS CRIMINAL 13Hq. Young offender OFFENDER JUVENILE YOUNG 13IB3 Child leaving care LEAVING 13IU. Adult no longer vulnerable VULNERABLE 13If0 Unborn child is cause for safeguarding concern UNBORN SAFEGUARDI 13JJ0 Benefits agency reports unfit for work 13JJ1 Benefit agncy reprt unfit for work but fit note no lngr need FIT 13KF. Stable income STABLE INCOME 13VX. At risk of sexual exploitation RISK EXPLOITATI 13VY. At risk of female genital mutilation FGM MUTILATION MUTILATION 13Va. Toilet downstairs DOWNSTAIRS 2 Vision 3 13Vb. Toilet upstairs UPSTAIRS 13Vc. No stairs in residence STAIRS RESIDENCE 13Vd. Access to residence by stairs STAIRS ACCESS 13Ve. Access to residence by steps STEPS RESIDENCE 13Vf. Primary carer has poor support network NETWORK SUPPORT PRIMARY 13Vg. Primary carer displays emotional warmth and love to child EMOTIONAL WARMTH LOVE 13Vh. Good attachment to primary carer ATTACHMENT 13We. Drug misuser in household MISUSER HOUSEHOLD 13Wf. Alcohol misuser in household MISUSER HOUSEHOLD 13Wg. No longer dependant of member of British Armed Forces BAF 13Z4Q Not receiving education RECEIVING 13ZC0 Person granted indefinite leave to remain in United Kingdom UK LEAVE 13cG0 Opioid tolerant OPIOID 13cG1 Opioid naive OPIOID 13cM0 Novel psychoactive substance misuse PSYCHOACTI 13dp. Born in Belarus BELARUS 13dq. Born in Republic of Moldova MOLDOVA 13dr. Born in Guernsey GUERNSEY 13ds. Born in Jersey JERSEY 13dt. Born in Isle of Man MAN ISLE 13du. Born in Faroe Islands FAROE 13dv. Born in Greenland GREENLAND 13dw. Born in Svalbard and Jan Mayen SVALBARD 13dx. Born in Aland Islands ALAND 13eq. Born in Christmas Island CHRISTMAS 13er. Born in Cocos (Keeling) Islands KEELING COCOS 13es. Born in Macao MACAO 13gq. Born in Democratic Republic of Congo CONGO 13gr. Born in Western Sahara WESTERN SAHARA 13jF. Born in United States Virgin Islands VIRGIN Read Dictionary Changes Quarter 3 2014 3 13jG. Born in Saint Vincent and the Grenadines GRENADINES VINCENT SAINT 13jH. Born in Sint Maarten SINT MAARTEN 13jJ. Born in Saint-Martin SAINT MARTIN 13jK. Born in Bonaire, Sint Eustatius and Saba BONAIRE SABA EUSTATIUS 13jL. Born in Curacao CURACAO 13kA. Born in Samoa SAMOA 13kB. Born in American Samoa SAMOA AMERICAN 13kC. Born in United States Minor Outlying Islands OUTLYING UNITED STATES 13kD. Born in Tokelau TOKELAU 13kE. Born in Cook Islands COOK 13kF. Born in Guam GUAM 13kG. Born in Federated States of Micronesia MICRONESIA FEDERATED 13kH. Born in Marshall Islands MARSHALL 13kJ. Born in Niue NIUE 13kK. Born in Norfolk Island NORFOLK 13kL. Born in Northern Mariana Islands MARIANA 13kM. Born in Palau PALAU 13kN. Born in Antarctica ANTARCTICA 13o87 Uses alternative and augmentative communication AAC AUGMENTATI ALTERNATIV 13o88 Uses Tadoma method for communication TADOMA 13t3. Born in British Virgin Islands VIRGIN 13t4. Born in Turks and Caicos Islands TURKS CAICOS 13t5. Born in Saint Helena, Ascension and Tristan da Cunha ASCENSION TRISTAN HELENA 13t6. Born in South Georgia and the South Sandwich Islands SANDWICH GEORGIA 13t7. Born in Falkland Islands FALKLAND 13t8. Born in British Indian Ocean Territory 13t9. Born in Cayman Islands CAYMAN 13tA. Born in Pitcairn Islands PITCAIRN 4 Vision 3 13v1. Born in Saint Pierre and Miquelon PIERRE MIQUELON 13v2. Born in Wallis and Futuna WALLIS FUTUNA 13v3. Born in French Polynesia POLYNESIA 13v4. Born in French Guiana GUIANA 13v5. Born in French Southern Territories TERRITORIE SOUTHERN 13v6. Born in Mayotte MAYOTTE 13v7. Born in Guadeloupe GUADELOUPE 13v8. Born in Reunion REUNION 13v9. Born in New Caledonia CALEDONIA 14Oj. At risk of dying before adulthood RISK 14Ok. At risk of asthma ASTHMA 14Ol. At risk of influenza related complication INFLUENZA COMPLICATI 14X60 Victim of sexual harassment HARASSMENT 14XH. Victim of child sexual exploitation EXPLOITATI VICTIM SEXUAL 14g0. Early childhood developmental disability DEVELOP 16F0. Functional urinary and faecal incontinence FUNCTIONAL 16Q0. Calculated fluid maintenance requirement in 24 hours 16Q1. Calculated fluid intake volume in 24 hours 17371 Wheezing in absence of colds WHEEZ 173h. Able to complete sentence in one breath ABLE SENTENCE BREATH 19E20 Functional encopresis ENCOPRESIS 19EJ. Able to distinguish stool and flatus ABLE STOOL FLATUS 1A230 Functional urinary incontinence FUNCTIONAL 1AH1. Aware of passing urine AWARE 1B1g. No hallucinations HALLUCINAT 1B57. Dizziness on lying still DIZZINESS 1BH4. No paranoid ideation PARANOID 1BH5. No delusions DELUSIONS 1BZ3. Progressive intellectual and neurological deterioration PIND 1Bd.. No hypomanic symptom HYPOMANI 1Be.. Psychotic symptoms absent PSYCHOTIC 1D840 Head movement aggravates symptom MOVEMENT 1DCD. Splitting pain SPLITTING 1DCE. Heavy pain HEAVY Read Dictionary Changes Quarter 3 2014 5 1DCF. Gnawing pain GNAWING 1DCG. Cramping pain CRAMPING 1DCH. Throbbing pain THROBBING 1DCJ. Tender pain TENDER 1DD.. Symptom restricts activity ACTIVITY 1F9E. Erratic eating pattern 1IH.. No thought disorder THOUGHT 1JN1. Suspected Lyme disease LYME 1JN2. Suspected erythema migrans MIGRANS ERYTHEMA 1M02. Shoulder joint painful on movement SHOULDER 1M03. Shoulder joint painful on external rotation 1M110 Ischaemic foot pain at rest ISCHAEMIC 1M111 Ischaemic foot pain when walking ISCHAEMIC 1M5.. Pattern of pain 1M50. Constant pain CONSTANT 1M51. Intermittent pain INTERMITTE 1M6.. Affective dimension of pain DIMENSION AFFECTIVE 1M60. Punishing with pain PUNISHING 1M61. Fearful with pain FEARFUL 1M62. Sickening with pain SICKENING 1M63. Tiring with pain TIRING 1zz11 Quarter 3 2014 2126C Alcohol dependence resolved ALCOHOL 2126D Cow's milk protein allergy symptoms resolved COWS PROTEIN 222a. Normal growth and development for age GROWTH DEVELOPMEN 22K92 Child body mass index less than 0.4th centile BMI 22K93 Child body mass index 0.4th-1.9th centile BMI 22K94 Child body mass index on 2nd centile BMI 22K95 Child body mass index 3rd-8th centile BMI 22K96 Child body mass index on 9th centile BMI 22K97 Child body mass index 10th-24th centile BMI 22K98 Child body mass index on 25th centile BMI 22K99 Child body mass index 26th-49th centile BMI 22K9A Child body mass index on 50th centile BMI 22K9B Child body mass index 51st-74th centile BMI 22K9C Child body mass index on 75th centile BMI 22K9D Child body mass index 76th-90th centile BMI 22K9E Child body mass index on 91st centile BMI 22K9F Child body mass index 92nd-97th centile BMI 6 YORKTOWN ADMINISTRA Vision 3 22K9G Child body mass index on 98th centile BMI 22K9H Child body mass index 98.1st-99.6th centile BMI 22K9J Child body mass index greater than 99.6th centile BMI 22K9K Down's syndrome body mass index centile BMI 2354. Baseline respiratory rate RESPIRATOR BASELINE 246n. Baseline blood pressure BASELINE 24c0. Baseline heart rate BASELINE 25T6. Parastomal hernia PARASTOMAL HERNIA 2816. Neurological examination NEUROLOGIC 294F. Scarf sign SCARF 2B6i. O/E - visual acuity R = 6/30 2B7i. O/E - visual acuity L = 6/30 2FY1. BCG granuloma GRANULOMA BCG 2FY2. Cutaneous complication of BCG immunisation BCG 2G4D0 Patellar apprehension test PATELLAR APPREHENSI 2G4D1 Patellar apprehension test positive PATELLAR APPREHENSI 2G4D2 Patellar apprehension test negative PATELLA 2H48. Normal range of shoulder movement SHOULDER 2H480 Normal passive range of shoulder movement SHOULDER 2H820 Decreased range of cervical spine movement 2Jc.. Medically fit for surgery MEDICALLY 2Jd.. Frailty FRAILTY 2Jd0. Mild frailty MILD 2Jd1. Moderate frailty MODERATE 2Jd2. Severe frailty SEVERE 2Je.. Multiple long term conditions 313R. Head thrust test HEAD IMPULSE THRUST 389H. Holistic needs assessment HOLISTIC 389J. Support Needs System assessment SNS NEEDS 389K. Pre-assessment questionnaire completed QUESTIONNA 389L. Psychological assessment PSYCHOLOGI 389L0 Psychological wellbeing assessment WELLBEING 389M. Early Help Assessment EHA 389N. Social assessment SOCIAL 389P. Spiritual assessment SPIRITUAL Read Dictionary Changes Quarter 3 2014 7 389Q. Pain assessment tool completed TOOL PAIN 38B6. Antenatal risk assessment ANTENATAL 38D80 IAPT programme work and social adjustment scale - work WSAS 38D81 IAPT programme WSAS - home management WSAS 38D82 IAPT programme WSAS - social leisure activities WSAS 38D83 IAPT programme WSAS - private leisure activities WSAS 38D84 IAPT programme WSAS - relationships WSAS 38Gt2 QAdmissions risk emergency hospital admission next 24 months QADMISSION 38Qe1 Sure Start Language Measure word count score WORD COUNT 38Qh. Glasgow Antipsychotic Side-effect Scale ANTIPSYCHO GLASGOW GASS 38Qi. SINBAD (site,isch,neuro,bact inf,depth) wound classification SINBAD 38Qj. DemTect scale DEMTECT 38Qk. GFI - Groningen Frailty Indicator FRAILTY GRONINGEN GFI 38Ql. FI - Frailty Index FRAILTY 38Qm. DASH (Dom Abuse Stalking Harassment HBV) 2009 Risk Checklist DASH STALKING HARASSMENT DOMESTIC HONOUR 38Qn. Mini-Cog MINICOG 38Qo. PAM - Patient Activation Measure PAM 38Qp. SURE (Sure myslf, Undersd info, Rsk-bnft rtio, Encrgmt) test SURE 38Qq. Short Physical Performance Battery SPPB BATTERY 38Qr. Oxford Cognitive Screen COGNITIVE OXFORD OCS 38Qs. Canadian Occupational Performance Measure COPM 38Qt. Generic Risk Indicators (Nat Risk Frwk Assess Child Yng Ppl) FRAMEWORK INDICATOR GENERIC 38Qu. Graded Care Profile GCP PROFILE GRADED 38Qv. Everyday Cognition questionnaire ECOG 38Qw. Resistanc Related Risk Indicat (N R Fwk Asses Child Yng Ppl) RESISTANCE INDICATORS 8 Vision 3 38Qx. My World Triangle assessment tool WORLD TRIANGLE 38Qy. Carer Support Needs Assessment Tool CSNAT 38Qz. Measure Yourself Medical Outcome Profile MEASURE OUTCOME MYMOP PROFILE 38T.. Assessment of parenting capacity PARENTING CAPACITY 38V.. Miscellaneous scales 2 38V0. Nottingham extended ADL index NEADL 38V1. Malcomess Care Aims Model AIMS MALCOMESS CARE 38V2. Dynamic Gait Index DYNAMIC INDEX GAIT 38V3. QBleed risk calculator QBLEED 38V30 QBleed 5 year risk of intracranial haemorrhage QBLEED 38V31 QBleed 5 year risk upper gastrointestinal haemorrhage QBLEED 398H. Able to transfer to vehicle independently VEHICLE TRANSFER 398J. Able to transfer to vehicle with supervision VEHICLE TRANSFER 398K. Able to transfer to vehicle with assistance ASSIST VEHICLE TRANSFER 42VS. Result consistent with haemoglobin C carrier 42VT. Result consistent with haemoglobin D carrier 42VV. Result consistent with haemoglobin E carrier 42VW. Result consistent with haemoglobin O-Arab carrier (finding) 42ZL. Eosin-5-maleimide binding site assay BINDING MALEIMIDE EOSIN 42jL0 Plasma factor XIII antigen concentration XIII FACTOR 42jL1 Plasma factor XIII activity XIII FACTOR 43IK. Plasma factor XIII activityHaemolytic complement (AP50) level AP50 43WiJ Beetroot specific IgE antibody level BEETROOT 43WiK Marguerite ox-eye daisy specific IgE antibody level MARGUERITE DAISY 43WiL Pollock specific IgE antibody level POLLOCK Read Dictionary Changes Quarter 3 2014 9 43WiM Finch feathers specific IgE antibody level 43XA. Hepatitis B core antibody positive 43bV. Chromatin immunoglobulin G antibody level CHROMATIN 43j01 Cytomegalovirus deoxyribonucleic acid detection assay CYTOMEGALO 43j02 Cytomegalovirus replication ribonucleic acid detection assay CYTOMEGALO 43j31 Dengue virus ribonucleic acid detection assay DENGUE 43j41 Hantavirus ribonucleic acid detection assay HANTAVIRUS 43j61 Herpes simplex deoxyribonucleic acid detection assay HERPES 43j71 HIV 1 provirus deoxyribonucleic acid detection assay HIV 43j72 HIV 1 ribonucleic acid detection assay HIV 43j81 HTLV 1 provirus deoxyribonucleic acid detection assay HTLV 43j82 HTLV 1 ribonucleic acid detection assay HTLV 43jB1 Parvovirus B19 deoxyribonucleic acid detection assay PARVOVIRUS 43jE1 HTLV 2 provirus deoxyribonucleic acid detection assay HTLV 43jE2 HTLV 2 ribonucleic acid detection assay HTLV 43jF1 Varicella zoster deoxyribonucleic acid detection assay VARICELLA 43jG1 Hepatitis B deoxyribonucleic acid detection assay HEPATITIS 43jM1 Adenovirus deoxyribonucleic acid detection assay ADENOVIRUS 43jN1 Arbovirus ribonucleic acid detection assay ARBOVIRUS 43jP1 Astrovirus ribonucleic acid detection assay ASTROVIRUS 43jQ1 Avian influenza virus ribonucleic acid detection assay INFLUENZA AVIAN 43jR1 BK polyomavirus deoxyribonucleic acid detection assay BK 43jS1 Coronavirus ribonucleic acid detection assay CORONAVIRU 43jV1 Epstein-Barr virus deoxyribonucleic acid detection assay BARR EPSTEIN EBV 43jW1 Hepatitis E ribonucleic acid detection assay HEPATITIS 43jX1 Human metapneumovirus ribonucleic acid detection assay MPV 43jY1 Human papilloma virus deoxyribonucleic acid detection assay HPV 43jZ1 JC virus deoxyribonucleic acid detection assay JC 43ja1 Measles virus ribonucleic acid detection assay MEASLES 43jb1 Molluscum contagiosum deoxyribonucleic acid detection assay MOLLUSCUM CONTAGIOSU 43jc1 Mumps virus ribonucleic acid detection assay MUMPS 43je1 Nipah virus ribonucleic acid detection assay NIPAH 43jf1 Norovirus ribonucleic acid detection assay NOROVIRUS 43jg1 Poxvirus deoxyribonucleic acid detection assay POXVIRUS 43jh1 Rabies virus ribonucleic acid detection assay RABIES 43ji1 Rhinovirus ribonucleic acid detection assay RHINOVIRUS 43jj1 Rotavirus ribonucleic acid detection assay ROTAVIRUS 10 FINCH FEATHER Vision 3 43jk1 Respiratory syncytial virus ribonucleic acid detection assay RSV 43jl1 Sapovirus ribonucleic acid detection assay SAPOVIRUS 43jm1 Rubella virus ribonucleic acid detection assay RUBELLA 43jn1 SARS virus ribonucleic acid detection assay SARS 43jo1 West Nile fever virus ribonucleic acid detection assay WEST NILE 43jr1 HTLV provirus deoxyribonucleic acid detection assay HTLV 43jr2 HTLV ribonucleic acid detection assay HTLV 43js1 Haemorrhagic fever ribonucleic acid detection assay HAEMORRHAG FEVER 43jt1 Human herpesvirus 6 deoxyribonucleic acid detection assay HHV 43ju1 Human herpesvirus 7 deoxyribonucleic acid detection assay HHV 43jv1 Human herpesvirus 8 deoxyribonucleic acid detection assay HHV 43jx1 Parainfluenza virus type 1 ribonucleic acid detection assay PARAINFLUE 43jy1 Parainfluenza virus type 2 ribonucleic acid detection assay PARAINFLUE 43jz1 Parainfluenza virus type 3 ribonucleic acid detection assay PARAINFLUE 43k91 GDH positive, C. diff toxin negative CLOSTRIDIU GDH DIFFICILE 43rZ. AMPA receptor immunoglobulin G antibody level AMPA 43w01 Poliovirus type 1 ribonucleic acid detection assay POLIOVIRUS 43w11 Poliovirus type 2 ribonucleic acid detection assay POLIOVIRUS 43w21 Poliovirus type 3 ribonucleic acid detection assay POLIOVIRUS 43w41 Herpes simplex type 1 deoxyribonucleic acid detection assay HERPES 43w51 Herpes simplex type 2 deoxyribonucleic acid detection assay HERPES 43w61 Influenza A virus ribonucleic acid detection assay INFLUENZA 43w71 Hepatitis A ribonucleic acid detection assay HEPATITIS 43w91 Parainfluenza virus type 4 ribonucleic acid detection assay PARAINFLUE 43wD1 Influenza B virus ribonucleic acid detection assay INFLUENZA 44CZ1 Serum aldolase activity ALDOLASE 44IC0 Serum adjusted calcium concentration ADJUSTED CALCIUM 44PL1 Estimated serum non-HDL cholesterol level HDL 44TB0 Haemoglobin A1c (diagnostic reference range) HBA1C 44TB1 Haemoglobin A1c (monitoring ranges) HBA1C 44TJ8 Baseline blood glucose level BASELINE 44TJ9 Blood glucose level after evening meal GLUCOSE 44TJA Blood glucose level during night GLUCOSE 44X80 Blood lead level (occupational units) LEAD 44X81 Blood lead level (clinical units) LEAD Read Dictionary Changes Quarter 3 2014 11 44YA5 Baseline SpO2 (oxygen saturation at periphery) SPO2 BASELINE 44h90 Plasma adjusted calcium concentration CALCIUM ADJUSTED 44lzX Random urine protein:creatinine ratio PROTEIN CREATININE 44un1 Red blood cell 6-methylmercaptopurine:6-thioguanine ratio THIOGUANIN METHYLMERC 451L. Acute kidney injury warning stage WARNING AKI 461C. Catheter urine sample CSU SAMPLE CATHETER URINE 46gw. Urine orotic acid:creatinine ratio OROTIC 47J0. Faecal calprotectin test indeterminate 47J1. Faecal calprotectin test invalid 47J2. Faecal calprotectin test positive 47J3. Faecal calprotectin test negative 4G9F. Calculus magnesium ammonium phosphate content 4IA6. Specimen unsatisfactory for evaluation 4IA7. Unsuitable specimen 4J3N. Human immunodeficiency virus drug resistance test RESISTANCE 4J3P. Human immunodeficiency virus type 1 subtype identification SUBTYPE HIV 4J3Q. Human immunodeficiency virus IgG avidity HIV AVIDITY 4L4K. BRAF targeted genetic testHuman immunodeficiency virus IgG avidity BRAF 4L4L. Calreticulin targeted genetic test CALR 4QB47 Serum total 25-hydroxy vitamin D level 5119. Imaging of brain requested 516.. Dual energy X-ray photon absorptiometry scan requested REQUESTED DEXA 61J1. Combined oral contraceptive pill contraindicated OCP 61J2. Progestogen only oral contraceptive contraindicated OCP 61b.. Uses vaginal hormone releasing ring USES RELEASING 62P30 Breastfeeding and supplementary bottle feed at dis from hosp BREAST BOTTLE 62PE. Breastfeeding at discharge from hospital BREAST 62PF. Bottle feeding at discharge from hospital BOTTLE 62X6. Gestation less than 28 weeks 6317. Born in transit to hospital TRANSIT 6318. Born in hospital BORN 12 Vision 3 633B. Antepartum stillbirth ANTEPARTUM 633C. Intrapartum stillbirth INTRAPARTU 633D. Order of birth at delivery ORDER BIRTH 63CG. One of quadruplets QUADRUPLET 63CH. One of quintuplets QUINTUPLET 63CJ. One of sextuplets SEXTUPLET 63CK. One of septuplets SEPTUPLET 63CL. One of multiple birth MULTIPLE BIRTH 648R. Mid-parental centile 64c0. Unseen child protocol UNSEEN 64c1. Comprehensive medical assessment COMPREHENS CMA 64g.. Mid-parental height HEIGHT 64h.. Predicted adult height HEIGHT 64i.. Centile age adjustment for gestational age ADJUSTMENT 64j.. Down's syndrome height centile HEIGHT 64k.. Down's syndrome weight centile WEIGHT 65C0. Booster yellow fever vaccination YELLOW 66AH3 Conversion to non-insulin injectable medication CONVERSION 66CF0 3 month target weight TARGET 66CF1 6 month target weight TARGET 66CF2 12 month target weight TARGET 66CF3 Target weight to achieve five percent weight loss 66CF4 Target weight to achieve ten percent weight loss 66F7. Monoclonal paraprotein threshold for referral MONOCLONAL THRESHOLD PARAPROTEI 66Yz4 Single inhaler maintenance and reliever therapy started THERAPY 66Z0. Prostate specific antigen threshold for referral PROSTATE THRESHOLD PSA 66o1. Enquiry about diabetic erectile dysfunction declined ERECTILE DYSFUNCTIO 671E1 Discussion about treatment with carer 671E2 Discussion about female genital mutilation with carer FGM CARER 6762. Education about thyroid disease in pregnancy THYROID 677C8 Carrier VLCAD (v lng chn acyl-CoA dehyd defic) gene mutation GENE VLCAD MUTATION 677W. Substance abuse counselling 67971 Education about vaccination Read Dictionary Changes Quarter 3 2014 VACCINATIO 13 679L3 Diabetic foot care education EDUCATION FOOT 679g0 Acne management education ACNE 679j. Medication education 679j0 Education about taking methadone METHADONE 679j1 Education about methadone storage METHADONE 679k. Education about access to Patient Facing Service 67A10 Provision of information about cow's milk protein free diet COWS MILK 67A11 Provisn of information about amino acid-based infant formula FORMULA AMINO 67A12 Prov information about extensively hydrolysed infant formula HYDROLYSED FORMULA 67A13 Provision of information about soya-based infant formula SOYA FORMULA 67DN. Provision of information about chicken pox POX CHICKEN 67DP. Discussion about clinical red flag warning signs RED FLAG 67DQ. Discussion about female genital mutilation FGM MUTILATION 67HA. Lifestyle education for diabetes EDUCATION 67I30 Education about weaning for cow's milk protein allergy 67IG0 Oral hygiene instruction OHI 67Iv. Advice about caffeine consumption CAFFEINE 67Iw. Advice to return if problem persists or deteriorates 67Ix. Further advice 67L2. Identifying personal goals GOALS 67P5. Discussion about cardiopulmonary resuscitation with family member CPR 68W2C Bowel scope (flexi-sig) screen: incidental findings 6AL.. Opportunistic patient review OPPORTUNIS 6AN.. Urgent care clinical dashboard patient review DASHBOARD 6AP.. Review of patient at risk of asthma RISK ASTHMA 6H... Brief intervention INTERVENTI BRIEF 793Py Other specified other cardioverter defibrillator SPECIFIED 793Pz Unspecified other cardioverter defibrillator UNSPECIFIE 7E04H Subtotl abdominal hysterectomy & bilat salpingo-oophorectomy SALPINGO OOPHORECTO 7E04J Subtotl abdominal hysterectomy & right salpingo-oophorectomy SALPINGO 7E04K Subtotal abdominal hysterectomy & left salpingo-oophorectomy SALPINGO OOPHORECTO 14 Vision 3 7E04N Radical hysterectomy with conservation of ovaries RADICAL CONSERVATI 7E04P Radical hysterectomy with bilateral salpingo-oophorectomy SALPINGO OOPHORECTO 7E057 Vaginal hysterectomy and right salpingo-oophorectomy SALPINGO OOPHORECTO 7E058 Vaginal hysterectomy and left salpingo-oophorectomy SALPINGO OOPHORECTO 7P0GA 72 hour ambulatory electrocardiographic monitoring ECG 8552. M technique on hands HANDS TECHNIQUE 8555. M technique on feet TECHNIQUE 8556. M technique on body TECHNIQUE 8866. Venepuncture VENEPUNCTU 8A59. Self-monitoring of blood pressure SELF BP 8AB4. Telehealth monitoring invitation 8B2B0 Issue of nicotine replacement therapy voucher 8B6k. Analgesic prophylaxis ANALGESIC 8BF6. EMMETT technique EMMETT 8BMa1 Optimisation of ACE inhibitor therapy INHIBITOR ACE 8BMe. Patient run out of prescribed medication 8BMf. Supply of urgent rpt medicatn by Community Pharmacy via PGD PHARMACY PGD 8BQ1. Long term indication for seasonal influenza vaccination INDICATION 8BT3. Anticoagulant medication review ANTICOAGUL 8CES. Unlicensed medication information leaflet given INFORMATIO UNLICENSED MEDICATION 8CET. Dementia leaflet given DEMENTIA 8CJ6. Structured reintroduction of cow's milk protein COWS PROTEIN MILK 8CMf. Ambulatory care pathway AMBULATORY 8CMg. End of life advance care plan EOL 8CN3. Discussion about advance care planning with family member DISCUSSION ACP 8CN4. Discussion about advance care planning with carer DISCUSSION ACP 8CN5. Discussion about advance care planning declined DISCUSSION ACP 8CN6. Discussion about ACP not appropriate at this time ACP DISCUSSION APPROPRIAT Read Dictionary Changes Quarter 3 2014 15 8CN7. Discussion about DNACPR not appropriate at this time APPROPRIAT DNACPR DISCUSSION 8CN8. Discussion about patient electronic health record EHR 8CT6. Birth to 25 educatn, health and care plan-based care stopped EHCP 8CT7. Stopped by healthcare professional PROFESSION HEALTHCARE 8CT8. Proactive care ended PROACTIVE 8CT9. Registration for access Patient Facing Service discontinued FACING 8CV8. Birth to 25 educatn, health and care plan-based care started EHCP 8CZ0. Provision of proactive care PROACTIVE 8Cr0. Cutting toenails of both feet 8Cr1. Cutting and filing of toenail 8Cr10 Cutting and filing of toenails of both feet 8Cr11 Cutting and filing toenails of left foot 8Cr12 Cutting and filing toenails of right foot 8Cr2. Cutting toenails of left foot 8Cr3. Cutting toenails of right foot 8Cs0. Filing toenails of both feet 8Cs1. Filing toenails of left foot 8Cs2. Filing toenails of right foot 8Ct.. Mellow Bumps Programme MELLOW BUMPS 8Cu.. Drilling of a nail DRILLING 8Cu0. Drilling toenails of both feet 8Cu1. Drilling toenails of left foot 8Cu2. Drilling toenails of right foot 8Cw.. Optimisation of clinical care OPTIMISATI 8GP.. Mindfulness-based therapy MINDFULNES 8HEC. Discharge from special care baby unit SCBU 8HHq0 Referral for depression self-help video VIDEO DEPRESSION 8Hgd. Discharge from secondary care diabetes service DIABETES SECONDARY 8Hge. Discharge from Prevention Matters service PREVENTION MATTERS 8Hly. Referral to community hub HUB COMMUNITY 8Hlz. Referral to multi-agency Single Point of Entry SPOE 8Hx.. Referral to clinical nurse specialist CLINICAL SPECIALIST 8Hx0. Referral to community Parkinson's disease clinical nurse specialist PARKINSONS 16 Vision 3 8Hx1. Referral to sickle cell specialist nurse SICKLE 8IH30 Anxiety screening declined ANXIETY 8IH31 Depression screening declined DEPRESSION 8IH4. Alcohol Use Disorders Identification Test declined AUDIT 8IH5. Referral declined REFERRAL 8IH50 Referral for mental health assessment declined 8IH51 Referral to community mental health team declined 8IH52 Referral for guided self-help for depression declined DEPRESSION 8IH53 Referral for guided self-help for anxiety declined ANXIETY 8IH54 Referral to psychiatrist declined PSYCHIATRI 8IH6. Over 75 health check declined CHECK 75 8K00. Bladder acupuncture points BLADDER BL 8K000 BL57 BL57 8K01. Chinese auricular points CHINESE AURICULAR 8K02. Chinese scalp SCALP CHINESE 8K03. Gallbladder acupuncture points GB GALLBLADDE 8K030 GB40 GB40 8K031 GB30 GB30 8K04. Heart acupuncture points HEART 8K040 HT7 HT7 8K05. Small intestine acupuncture points SI INTESTINE SMALL 8K050 SI11 SI11 8K051 SI13 SI13 8K06. Stomach acupuncture points STOMACH ST 8K060 ST36 ST36 8K07. Spleen acupuncture points SPLEEN SP 8K070 SP6 SP6 8K08. Pericardium acupuncture points PERICARDIU PC 8K080 PC6 PC6 8K09. Large intestine acupuncture points LARGE INTESTINE LI 8K090 LI14 LI14 Read Dictionary Changes Quarter 3 2014 17 8K0A. Liver acupuncture points LV LIVER 8K0A0 LR3 LR3 8MF.. Request for access to Patient Facing Service FACING 8OAE. Provision of written informtn about blood glucose monitoring GLUCOSE BLOOD 8OAF. Provision written information about access Pt Facing Service FACING 8OC.. Provision of access to Patient Facing Service FACING 8T050 Referral to dementia support organisation SUPPORT 8T051 Referral to dementia support organisation declined 8T0W. Referral to children and families service FAMILIES CHILDREN 8T0X. Referral to Prevention Matters service PREVENTION MATTERS 8W1.. Refer to MH services deferred until substance misuse resolvd DEFERRED 8W2.. Refer to MH services deferred until alcohol misuse resolved DEFERRED 918D0 Name of care coordinator COORDINATO 918f0 No longer carer of patient with dementia DEMENTIA 91D.. Registered with violent patient scheme VIOLENT SCHEME 934A. Electronic Personal Child Health Record CHILD 93C5. Sharing ACP decisions with out of hours service OOH ACP 93G.. Genogram GENOGRAM 93H.. Ecomap ECOMAP 949F. Died in ambulance AMBULANCE 949G. Patient died in hospice community lodge LODGE HOSPICE 94ZG. Preferred place of death: hospice community lodge HOSPICE LODGE 98G.. Multidisciplinary meeting MULTIDISCI MEETING 9EVC. Cervical smear report received SMEAR 9EVD. Hospital alcohol liaison team report received ALCOHOL 9EZ0. Medical report fee paid 9FB.. Subject of court care proceedings under Children Act 1989 PROCEEDING COURT 9KD.. Early Help Assessment Form completed EHA 9N1yL Seen in sexual health clinic SEXUAL HEALTH 9N320 Email received from third party EMAIL 9N471 Referral cancelled by patient 18 Vision 3 9N6r. Referral by clinical nurse specialist 9N6s. Referral by hospital-based dietitian 9N6t. Referral by community-based dietitian DIETITIAN 9NNm. Has named person (Getting It Right For Every Child) NAMED GIRFEC 9NNn. Has lead professional (Getting It Right For Every Child) GIRFEC PROFESSION LEAD 9NNo. Integrated care coordinator identified INTEGRATED 9NNp. Under care of Prevention Matters service PREVENTION MATTERS 9NSM. Erectile dysfunction screening not appropriate ERECTILE DYSFUNCTIO 9NSN. Chlamydia screening not appropriate CHLAMYDIA 9NSP. Declined invitation to attend care planning appointment 9NSQ. Wishes to participate in remote care monitoring 9NSR. Unsuitable for Over 75 Health Check 9NV4. Post hospital discharge followed up within 3 days 9Nc2. Referral letter sent SENT 9Nc20 Referral letter sent by email EMAIL 9Nc21 Referral letter sent by fax FAX 9NfH. Requires information by email EMAIL 9NfJ. Requires information in electronic audio format AUDIO 9NfK. Requires information in Moon alphabet MOON 9NfL. Requires information in Makaton MAKATON 9NfM. Requires information in contracted (Grade 2) Braille BRAILLE 9NfN. Requires information in uncontracted (Grade 1) Braille BRAILLE 9NfP. Requires contact by short message service text message SMS 9NfQ. Requires contact by letter LETTER 9NfR. Requires contact by email EMAIL 9Ngz2 Under care of school nursing service NURSING 9Ngz3 Under care of school nursing service - Universal UNIVERSAL NURSING 9Ngz4 Under care of school nursing service - Universal plus NURSING UNIVERSAL PLUS 9Ngz5 Undr care of school nrsing srvce - Universal partnrship plus NURSING PLUS PARTNERSHI UNIVERSAL 9Ngz6 Eligible for Healthy Start voucher HEALTHY 9Ngz7 Removed from violent patient scheme VIOLENT SCHEME Read Dictionary Changes Quarter 3 2014 CLINICAL REMOTE 19 9Ngz8 Under care of Youth Justice Service YOUTH JUSTICE 9Ngz9 In transition from children's to adult care service ADULT TRANSITION CHILDREN 9NgzA Under care of adult care service SERVICE ADULT 9NgzB Eligible for integrated care pathway PATHWAY INTEGRATED 9Nil. Did not attend antenatal appointment ANTENATAL 9Nim. Did not attend nurse appointment 9Nin. Did not attend general practitioner appointment GP 9NkQ. Seen in sexual assault referral centre ASSAULT SEXUAL SARC 9Nlf. Seen by community falls team FALLS 9Nlg. Seen by brain injury link worker BRAIN WORKER INJURY 9NnQ. Sign Supported English interpreter needed SUPPORTED SIGN 9NoE. Seen in spinal clinic SPINAL 9NoF. Seen in preoperative assessment clinic PREOPERATI 9Nt40 Seen by consultant bariatric physician BARIATRIC 9NuB. Express consent for Emergency Care Summary upload ECS SUMMARY EMERGENCY 9NuC. Consent given to receive test results by telephone GIVEN RESULTS PHONE 9NuE. Consent given to contact patient regarding test result PATIENT CONTACT 9Nz3. Appropriate use of accident and emergency service APPROPRIAT 9Nz4. Appropriate use of walk-in centre APPROPRIAT 9Nz5. Inappropriate triage decision TRIAGE 9Nz6. Appropriate triage decision TRIAGE 9Nz7. Father present at encounter FATHER 9Nz8. Mother present at encounter MOTHER 9OF9. MMR booster vaccination invitation third letter MMR BOOSTER 9OFA. MMR booster vaccination invitation second letter MMR BOOSTER 9OFB. MMR booster vaccination invitation first letter MMR BOOSTER 20 Vision 3 9OJB. Asthma monitorng invit SMS (short message servce) txt messge TEXT SMS 9OJC. Asthma monitoring invitation email EMAIL 9OqG. Everyday Cognition questionnaire completed ECOG 9P110 Entered into drug clinical trial 9PF.. Entered into device clinical trial 9Rb.. Registration for access to Patient Facing Service FACING 9b0a1 Inpatient nursing note NURSING 9lP.. Parent held personal child health record checked CHECKED 9lQ.. Blood glucose self-monitoring record checked 9lR.. Patient has no paper record 9lS.. MOD Personal Medical Record F MED 4 closed and archived MOD FMED4 9lT.. Video record of patient encounter available VIDEO 9lV.. Medical record sent by Health Authority RECORD HA 9lW.. Registered for access to Patient Facing Service FACING 9lX.. Access to Patient Facing Service denied FACING 9m44. Healthy lifestyle programme offered 9mT.. Latent tuberculosis screening invitation 9mT0. Latent tuberculosis screening invitation first letter 9mT1. Latent tuberculosis screening invitation second letter 9mT2. Latent tuberculosis screening invitation third letter 9mT3. Latent tuberculosis screening invitation email 9mT4. Latent tuberculosis screening telephone invitation 9mT5. Latent tuberculosis screening telephone invitation 9mT6. Latent tuberculosis screening offered 9mT7. Latent tuberculosis screening declined 9q7.. Declind consent use pt data in rsk stratifctn unplnnd admiss STRATIFICA UNPLANNED 9q8.. Consent given to discuss PPC with carer PPC 9q9.. Consent given to discuss PPC with family member PPC A3BD. Infection due to carbapenemase producing Enterobacteriacea ENTEROBACT CARBAPENEM A4110 Sporadic Creutzfeldt-Jakob disease CJD SPORADIC CREUTZFELD A8711 Lyme neuroborreliosis LYME BORRELIOSI A8712 Lyme carditis LYME A8713 Borrelial lymphocytoma BORRELIAL LYMPHOCYTO LYME Read Dictionary Changes Quarter 3 2014 LATENT TUBERCULOS 21 C300A Congenital Fanconi syndrome FANCONI C300B Dibasic aminoaciduria - type I DIBASIC AMINOACID C300C Lysinuric protein intolerance AMINOACID C300D Infantile nephropathic cystinosis C300E Dibasic aminoaciduria DIBASIC AMINOACID C346. Acute exacerbation of gout EXACERBATI ACUTE C354C Cortical nephrocalcinosis NEPHROCAL CORTICAL C354D Familial hypocalciuric hypercalcaemia FAMILIAL HYPERCALCA FHH HYPOCALCIU C3653 Dehydration DEHYDRATIO C3662 Idiopathic oedema IDIOPATHIC C3990 Mannose-binding lectin deficiency MANNOSE MBL F4C57 Conjunctival amyloidosis CONJUNCTIV AMYLOIDOSI Fy06. Kleine-Levin syndrome LEVIN KLEINE G7211 Congenital renal artery aneurysm RENAL ANEURYSM G72B0 Dissection of transplant artery J1017 Eosinophilic oesophagitis J5211 Irritable bowel syndrome characterised by constipation J5212 IBS characterised by alternating bowel habit K01w2 Congenital nephrotic syndrome with focal glomerulosclerosis NEPHROTIC K036. Cryoglobulinaemic glomerulonephritis GLOMERUL CRYOGLOB K073. Diffuse mesangial sclerosis with ocular abnormalities MESANGIAL K0811 Congenital nephrogenic diabetes insipidus NEPHROGEN K08yH Familial renal hypouricaemia FAMILIAL K1014 Emphysematous pyelonephritis PYELONEP EMPHYSEM K1015 Emphysematous pyelitis PYELITIS EMPHYSEM M232. Involuted toenail INVOLUTED M2y26 Dystrophic calcification of skin DYSTROPHIC CALCIFICAT M2y91 Cutaneous amyloidosis CUTANEOUS AMYLOIDO 22 EOSINOPHIL Vision 3 N11F. Axial spondyloarthritis SPONDYLOAR AXIAL N23yF Muscle crush syndrome CRUSH PD1y1 Cortical cystic disease CORTICAL PD8.. Congenital abnormality of the kidney KIDNEY PD80. Duplex kidney DUPLEX PKy06 Feingold syndrome FEINGOLD SN533 Atopy ATOPY SN58B Allergy to banana BANANA SP07T Anterior capsular phimosis PHIMOSIS SP08b De novo glomerulonephritis NOVO GLOMERUL SP08c De novo transplant disease NOVO SP0H. Disorder associated with dialysis DIALYSIS SP0H0 Dialysis disequilibrium ZV405 [V]Disorder of attention ZV62A [V] Gender dysphoria Read Dictionary Changes Quarter 3 2014 DYSPHORIA 23 Read Codes Changes for this Release Read Code Read Term 7M3.. Type of operation and anaesthetic 7M37. Other non-operations 7M370 Application of transcutaneous electrical nerve stimulator 7M371 Radiotherapy NEC 7M372 Scanning NEC 7M373 Barium meal performed 7M374 Barium enema performed NEC 7M37y Other specified other non operations 7M37z Other non operations NOS 7M3y. Other specified type of operation or anaesthetic 7M3z. Type of operation or anaesthetic NOS 7My.. Other specified subsidiary classification of operations 7Mz.. Subsidiary classification of operations NOS Read Codes Deleted for this Release There were no Read codes deleted for this release. 24 Vision 3 Other Term Keys Added for this Release Read Code 43T.. Read Term Lyme borreliosis test Keyword LYME BORRELIOSI A8710 Lyme borreliosis BORRELIOSI LYME F4B44 Corneal calcification CORNEAL G754. Granulomatosis with polyangiitis POLYANGIIT GRANULOMAT H14y0 Tonsillolith TONSILLOLI J091. Lingual erythema migrans MIGRANS ERYTHEMA K578. Female genital mutilation FGM N010A Lyme arthritis LYME N122. Lumber disc bulge BULGE SN50. Anaphylaxis ANAPHYLAXI Term Keys Changed for this Release Read Code Read Term Keyword 122B0 No FH of breast cancer meeting NICE CG126 referral criteria NICE 44IC. Corrected serum calcium level CALCIUM CORRECTED 9Z... 2014-10-01 JDR1 Rz... 2014-10-01 JDR Read Dictionary Changes Quarter 3 2014 25 Term Keys Deleted for this Release Read Code Read Term Keyword 122B0 No FH of breast cancer meeting NICE CG126 referral criteria CRITERIA 44IC. Corrected serum calcium level LEVEL SERUM ADJUSTED Synonym Keys Added for this Release Read Code Read Terms Keyword 13Hq.11 Juvenile offender JUVENILE 14g0.11 Early developmental impairment DEVELOP 313R.11 Head impulse test HEAD IMPULSE 38Qv.11 ECog (Everyday Cognition) questionnaire ECOG 43T..11 Lyme borreliosis test LYME BORRELIOSI 8K00.11 BL - Bladder acupuncture points BLADDER BL 8K03.11 GB - Gallbladder acupuncture points GB 8K04.11 HT - Heart acupuncture points 8K05.11 SI - Small intestine acupuncture points SI INTESTINE SMALL 8K06.11 ST - Stomach acupuncture points STOMACH ST 8K07.11 SP - Spleen acupuncture points SPLEEN SP 8K08.11 PC - Pericardium acupuncture points PERICARDIU PC 8K09.11 LI - Large intestine acupuncture points LARGE INTESTINE LI 8K0A.11 LV - Liver acupuncture points LV LIVER 9OqG.11 ECog (Everyday Cognition) questionnaire completed ECOG A411011 Sporadic CJD (Creutzfeldt-Jakob disease) A871011 Lyme borreliosis AA41.11 Erythema migrans 26 BORRELIOSI LYME Vision 3 C300C11 Dibasic aminoaciduria - type II AMINOACID F4B4411 Corneal calcification CORNEAL G754.11 Granulomatosis with polyangiitis POLYANGIIT GRANULOMAT H14y012 Tonsillolith TONSILLOLI J091.11 Lingual erythema migrans MIGRANS ERYTHEMA K01w012 Congenital Finnish nephrosis N010A11 Lyme arthritis LYME N122.12 Lumber disc bulge BULGE SN50.11 Anaphylaxis ANAPHYLAXI Synonym Keys Deleted for this Release Read Code Read Terms Keyword 44IC.11 Adjusted serum calcium level ADJUSTED Read Dictionary Changes Quarter 3 2014 27 Index C Copyright Notice • ii I Introduction • 1 O Other Term Keys Added for this Release • 25 R Read Codes and Keywords Added for this Release • 2 Read Codes Changes for this Release • 24 Read Codes Deleted for this Release • 24 Read Dictionary Changes Quarter 3 2014 • 1 S Summary • 1 Synonym Keys Added for this Release • 26 Synonym Keys Deleted for this Release • 27 T Term Keys Changed for this Release • 25 Term Keys Deleted for this Release • 26 Index 29
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