Click below to download the new SCIMP Recommended codelist 2019.
Copy of SCIMP Recommended codelist 2019.3 111119 Read Only
This recommended codelist replaces the SCIMP 800 and work is being performed for this codelist to be utilised by new GP software systems. The version on the website contains SCIMP recommended Read Codes only, SNOMED CT terms are available on request. You can search for a term using “ctrl f” to find a recommended code.
Would like to thank all of those who assisted building this list!
Feel free to share this and utilise this with your current GP teams.
Codelist for General Practice
SCIMP 2019.3
Background
Accuracy, completeness and consistency in the coding of patient records (Data Quality) provide numerous clinical, safety and administrative benefits for the day to day business of general practice. Increased Data Quality has the potential to improve individual patient contacts, validity of computer safety alerts, the sharing of data out with the practice e.g. via outpatient referrals and Key Information Summaries. In addition this aids patient management in recalls, audits and generation of reports.
In the early days of IT use within Scottish General Practice SCIMP produced a list of 800 recommended Read Codes. The list mostly consisted of diagnostic codes for major conditions or procedures and was to encourage all practices across Scotland to develop patient summaries and to assist in appropriate selection of codes for this purpose. There were also merits in encouraging consistent coding across practices. Since then this list underwent several revisions, in particular to accommodate coding requirements for Quality Outcome Framework (QOF). QOF required the addition of a wider range of codes to include administrative, examination and investigation codes.
Since then there has been a rapid expansion of the use of coding within General Practice, with the management of patients records becoming increasingly paperless. Read codes have stopped being updated in the UK since 2016 and there is a gradual introduction of SNOMED CT terminology in its place. The two current clinical systems in Scottish practices utilise Read codes, however there is a re-provisioning process currently underway for future GP software systems. This is thought to introduce a graded move to SNOMED CT, with dual coding. To do this new software systems are likely to utilise a UK mapping utility from Read2 to SNOMED CT. This process provides an opportunity to integrate an updated code formulary into future systems which can build on past work performed for the original SCIMP 800 list and for other codesets such as for Out of Hours.
Aims of Codelist ‘SCIMP 2019.2’
- To provide a recommended codelist for summarisation of previous medical records.
- To assist the day to day data entry, both within the consultation and also for administration purposes.
- To improve the quality and consistency of coding and record keeping in practices across Scotland.
- To ensure appropriate mapping from the Scottish version of Read2 to SNOMED CT utilising NHS Digital mapping tables. In some cases this has led to adjustments of the Read code to enable similar term mappings.
Method
An extended list was developed, organised by Read chapters. This extended list incorporated the original SCIMP list and included other additional codesets. Relevant enquiries to SPIRE, OOH’s codesets and other clinicians with an interest in General Practice and Clinical Informatics occurred. A clinical informatician working in SCIMP reviewed each code in the list and made adjustments deleting, changing or added codes from the wider Read formulary that they deemed necessary from knowledge of national strategies and clinical judgement. Several clinical informaticians were involved in this process.
These codes were then mapped to SNOMED CT. The following programmes were utilised:
- Clinical Terminology Browser 5-byte Version 2 Read Codes (Scottish) 2016-04-01
- Read v2 to SNOMED CT Mapping Lookup (June 2019 and subsequently October 2019 release) https://hscic.kahootz.com/
If a provisionally included Read term corresponded exactly to the SNOMED CT term this was included. If a provisionally included Read term did not then SNOMED CT was explored to see what other Read codes have been mapped to the same term. This meant that not uncommonly Read code synonyms were selected for the SCIMP 2019.2 code list.
If possible Read codes were selected that did not include the following:
[X], NOS, NEC, [M], [D], Other, with the aim of making terms more understandable to staff.
However this was not always possible and the priority was given to the Read code that closest matched the SNOMED CT term.
The final list was checked for accuracy by Clinical Coding tutors within the Teminology Service ISD.
Notes for Implementation
Where a synonym provides a better term or mapping to SNOMED CT these have all been identified by the Term code being added. Where there is no term code displayed this is assumed to be 00
Assumption that there will be the ability to drill down to more specific codes in hierarchy from the recommended codes.
Recommendations as to how this list will be presented within systems to enable ease of use for the users in General Practice have not been made. It is assumed this may differ depending on system.
Thought should be given as to how the most common terms are presented at top lists to users, and how users identify codes quickly. Keywords, picklists or user defined subsets could be considered. Functional searches for codes with an ‘autocomplete’ (suggested word completion abilities, based on this codelist) ability would be beneficial.
There are several areas which this list does not address on the assumption that the IT providers will have in-built mechanisms to enable appropriate data entry in these areas. These include:-
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· Allergies |
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· Basic Health data, smoking, alcohol, exercise, diet status |
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· Coding for entry of values. This includes results, basic measurements such as BP |
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· Ethnicity |
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· Family History |
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· Investigation results such as ECG’s, colonoscopies etc. |
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· Laboratory / Radiology results |
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· Occupation (other than high level code) |
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· On examination results |
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· ‘Seen by’ or ‘referred to’ coding |
Of note there is one code that requires to be listed, which has a significant problem with the mapping of Read2 to SNOMED CT. This is the Read Code: 8H230 ‘Emergency psychiatric admission MHA’ which maps SNOMED CT term ‘Emergency psychiatric admission under Mental Health Act 1983 England and Wales’, a more detailed term. This has been raised this with NHS Digital.
Future work
SCIMP could look to expand and review the codelist depending on individual needs of the IT providers and users. As needs may differ for each system it is complex to plan this in advance without further discussion.
As utilisation of SNOMED CT within IT systems develops there are likely to be opportunities to review and expand this list further. SNOMED CT is being updated every six months.
This codelist should be reviewed at regular intervals. The ability to deploy an updated codelist nationally would be highly desirable, particularly to allow urgent updates. It is anticipated that when used, after initial user feedback, there would be a desire to add further desirable codes fairly rapidly.
In addition due to ongoing changes within the NHS in Scotland, with the integration of Health and Social Care and particularly with the increasing integration of other health professionals within practices, there will be a demand for further changes within this list.
30th September 2019