The development of the read codes for speech and language therapy: feat or folly?

Abstract

ABSTRACT If person‐based systems are to capture and share the essence of an indivudal's clinical record, those systems must be able to record clinical terms meaningfully and their meanings must be common across the National Health Service (NHS). The vehicle for achieving this is the national thesaurus of coded clinical terms and groupings. The NHS Centre for Coding and Classification was established in 1990 as part of the Information Management group to maintain and develop the read codes. The read codes are a comprehensive, hierarchically arranged, thesaurus of terms used in healthcare. Terms have been coded, structured for use in computers, cross‐referenced to important national and international classifications, and are dynamic. The read codes are comprehensive, hierarchically coded, computerised, cross‐referenced, and are also dynamic. We have a thesaurus of terms to: (1) use in clinical computer systems; (2) facilitate the sharing of information among healthcare workers; (3) provide a basis for the exchange and analysis of information on every aspect of patient care; (4) satisfy the clinical data requirements for care plans, protocols, decision support, research, audit, planning, management and epidemiology. The clinical terms projects include (1) the clinical (medical) terms project; (2) the professions allied to medicine (PAMS) project; (3) the nursing, midwifery and health visiting terms project. The speech and language therapy project was launched in March 1991 to develop a comprehensive list of terms used by speech and language therapists (SLTs) in maintaining clinical records. Unlike our medical colleagues we had no previous systems to start from. An initial work plan was devised, based on a clinical record, using the categories of patient complaints, history, diagnositic terms, assessment, aids and appliances, and acronyms. The specialist advisor network and the members of the working group were consulted in the development and revision of the lists. This workplan was to be revised many times in the light of the wishes of the NHS Centre for Coding and Classification and many problems and issues arose, including: (1) how can many different professional approaches to the same issue be reconciled to produce a coherent set of terms?; (2) where do the boundaries of work covered by each profession begin and end?; (3) how can you code the terms used in assessment and treatment? The creation of a truly multidisciplinary set of termsfor the PAMs has not been attempted before. How to represent the common or natural language in clear and umambiguous terms. How to develop a clear method of terming what a client can or cannot do, and what you, as a therapist, are going to do, and how you are going to do it. Many of these issues are currently under discussion after recognition that coding for the PAMs is not a simple task. Great progress has been made in the medical profession at the NHS Centre for Coding and Classification accepting the depth and complexity of our work and in educating them about communication. Much work has yet to be completed before we have a working and comprehensive set of terms, but the foundation stones have been laid.