Abstract
The Read Codes from the United Kingdom are a comprehensive clinical vocabulary, and one of the most likely candidates for adoption as a standard for use in Computer-Based Patient Record (CPR) systems. The new version 3.1 codes represent a major enhancement to the content and structure of the coding system, including incorporation of a new hierarchy and an explicit model for the use of qualifier terms. This is a preliminary study investigating the suitability of these codes for representing clinical problem assessment phrases in U.S. family practice. Problem assessment phrases from outpatient progress notes were encoded into the equivalent Read terms. The problem assessment phrases were evaluated for complexity and clarity. The coded representations of the phrases were evaluated for clinical acceptability. A list of coding difficulties was compiled. The most common difficulties were (1) qualifier terms present but not allowable for that Read concept (24%), and (2) qualifier terms not present (20%). British spelling and abbreviation variants were noted, but were relatively insignificant. The Read codes appear to be suitable for use in U.S. primary care practice with fairly minor modifications, but further development is required to expand the content and structure of the model for qualifier terms.
Full text
PDF
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Campbell K. E., Das A. K., Musen M. A. A logical foundation for representation of clinical data. J Am Med Inform Assoc. 1994 May-Jun;1(3):218–232. doi: 10.1136/jamia.1994.95236154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cimino J. J., Clayton P. D., Hripcsak G., Johnson S. B. Knowledge-based approaches to the maintenance of a large controlled medical terminology. J Am Med Inform Assoc. 1994 Jan-Feb;1(1):35–50. doi: 10.1136/jamia.1994.95236135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rosenberg K. M., Coultas D. B. Acceptability of Unified Medical Language System terms as substitute for natural language general medicine clinic diagnoses. Proc Annu Symp Comput Appl Med Care. 1994:193–197. [PMC free article] [PubMed] [Google Scholar]
- Weed L. L. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593–600. doi: 10.1056/NEJM196803142781105. [DOI] [PubMed] [Google Scholar]