Development of the Read Code Thesaurus for community nursing

Abstract

Paper-based documentation systems have been found to be time consuming to maintain and do not necessarily support and enhance the care provided by nurses, midwives and health visitors. There is evidence that computerised clinical information systems can improve the quality and completeness of care planning, assessments, evaluations and audits, in addition to improving resource utilisation. An important infrastructural component of the Information Management and Technology Strategy for the NHS in England is the development of a multiprofessional national thesaurus of coded clinical terms, utilising Read Codes for use in computerised clinical information systems. The contribution made by community nurses, midwives and health visitors reflects how their work focuses on prevention, health promotion and health education, involving the whole community. Feedback from real working implementations of the thesaurus in operational clinical information systems is required in order to fully evaluate its comprehensiveness and usability.