Read Coding & Summarising Training for Beginners

This session is for any primary care staff who regularly enter data into patients’ medical records

As this is a basic session, it will be ideal for new staff members and those who require refresher Read Code training.

This session will improve your understanding of read codes, their importance and the negative impact of inconsistent data entry for the patient and for practice performance.

Read Codes are pivotal to every piece of data we enter into our clinical systems, as they determine:

• Patient’s past medical history
• Patient’s on-going clinical care
• Clinical governance
• Income

Given its importance, it is essential that everyone who enters patient data has received the appropriate training.

Whilst it is not necessary to attend an in-depth course on read codes, there are key messages which all staff should be aware of when entering data.

• What are Read Codes?
• Why do we need to code?
• Using Read Codes
  – How the Hierarchy/structure works
  – Read Code Chapters
  – Searching for the right Codes
  – Making coding easier
• Browsing the Hierarchy
• Abbreviations within Codes
• Data Quality
  – Adding a diagnosis
  – Improving Data Quality
• What is a summary
• Why do we summarise, why are they important?
• What do we summarise
• What not to summarise
• Updating/editing patient summaries
• Preparation
• The summarising process
• Scenarios