Read Codes Version 3: a user led terminology

Abstract

Version 3 of the Read Codes was designed in response to a new set of requirements generated by three new terming initiatives in the UK, the Clinical Terms Project, the Professions Allied to Medicine Terms Project and the Nursing Terms Project. The challenge was to cope with the detail required by clinical specialists for maintaining a computerised record, to capture the natural language used by clinicians in their everyday work, and to support efficient analysis across medical records required to extract information from clinicians' individual patient data. The structure of Version 3 allows a directed acyclic graph to replace the traditional hierarchy; permits multiple such graphs if necessary; introduces qualifiers, embedding these in an information model to support analysis; introduces one-to-many mapping to external classifications where this is necessary; and maintains the tradition of a dynamic terminology that stresses the inclusion of natural clinical terms.