The application of Read Codes to anaesthesia

Area of Science:

• Medical Informatics
• Anesthesiology

Background:

• The Clinical Terms Project's Anaesthetic Specialty Working Group is developing standardized terminology for anesthesiology.
• Existing systems lack consistent methods for describing anaesthetist activities.

Purpose of the Study:

• To create a comprehensive set of terms for anaesthesia.
• To facilitate the use of these terms in computerized systems, including automated anaesthetic record-keeping.
• To outline the methodology and rationale behind the term development.

Main Methods:

• Development of a standardized terminology set by the Anaesthetic Specialty Working Group.
• Coding of terms using Read Codes.
• Planning for introduction into the National Health Service.

Main Results:

• A new set of anaesthesia terms has been created.
• These terms are designed for computerized applications, enhancing anaesthetic record-keeping.
• The terms are coded as Read Codes for integration into health systems.

Conclusions:

• The developed anaesthesia terms will standardize documentation within the National Health Service.
• Implementation in 1994 aims to improve the efficiency and accuracy of anaesthetic record-keeping.
• The terminology provides a framework for describing anaesthetist activities in digital health records.