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Top level chapter descriptions for the Read controlled clinical terminology version 3 (CTV3) (compiled from NHS TRUD uk_readctv3xmap_25.0.0_20180401000001)
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chapter | description | |
---|---|---|
0. | Occupations | |
01 | Top managers | |
02 | Management support professions | |
03 | Education/welfare/health prof. | |
04 | Literary/artistic/sports occ. | |
05 | Prof. scientists/engin/technol | |
06 | Managerial occupations | |
07 | Clerical occupations | |
08 | Selling occupations | |
09 | Security/protective services | |
0A | Catering/personal services | |
0B | Farming/fishing occupations | |
0C | Materials processors exc metal | |
0D | Making/repairing ex metal/elec | |
0E | Metal/electrical workers | |
0F | Painters/product assemblers | |
0G | Product inspectors/packagers | |
0H | Construction/mining workers | |
0I | Transporting/moving/storing | |
0Z | Other occupations | |
1. | History / symptoms | |
11 | Depth of history | |
12 | Family history | |
13 | Social/personal history | |
14 | Past medical history | |
15 | Gynaecological history | |
16 | General symptoms | |
17 | Respiratory symptoms | |
18 | Cardiovascular symptoms | |
19 | Gastrointestinal symptoms | |
1A | Genitourinary symptoms | |
1B | Nervous system symptoms | |
1C | Ear/nose/throat symptoms | |
1D | General symptom description | |
1E | Rare history finding | |
1F | Dietary history | |
1G | Concerned about appearance | |
1H | Awareness of diagnosis | |
1I | Disorder excluded | |
1J | Suspected condition | |
1K | Gender | |
1L | Temporal observations | |
1M | Pain | |
1N | Symptoms of skin and integumentary tissue | |
1O | Disorder confirmed | |
1P | Behaviours and observations relating to behaviour | |
1Q | Character trait observations | |
1R | Resuscitation status | |
1S | Mental and psychological observations | |
1T | History of substance misuse | |
1V | Drug misuse behaviour | |
1W | Possible condition | |
1X | NHS Sickle Cell and Thalassaemia Screening Programme family origin | |
1Y | Patient feels well | |
1Z | History/symptom NOS | |
1a | Social/personal history additional | |
1b | Sexual orientation | |
1z | Read Code Administration | |
2. | Examination / Signs | |
21 | Depth of examination | |
22 | General examination of patient | |
23 | Examn. of respiratory system | |
24 | Exam. of cardiovascular system | |
25 | Exam. of digestive system | |
26 | Exam. of genitourinary system | |
27 | Obstetric examination | |
28 | Nervous system and mental state general examination | |
29 | Motor/sensory systems exam. | |
2A | Examination of reflexes | |
2B | Central nervous system exam. | |
2C | Haemopoietic system exam. | |
2D | Ear, nose + throat examination | |
2E | Examination of fever | |
2F | Examination of skin | |
2G | Examination of the extremities | |
2H | Orthopaedic examination | |
2I | General sign qualifications | |
2J | General clinical states | |
2K | Examination of abdomen | |
2L | Neonatal examination | |
2Z | Examination/signs NOS | |
3. | Diagnostic procedures | |
31 | Special diagnostic procedures | |
32 | Electrocardiography | |
33 | Physiological function tests | |
34 | Non-surgical biopsy (admin) | |
35 | Surgical biopsy (admin) | |
36 | Endoscopy / administration | |
37 | Exploratory diagn. procedures | |
38 | Misc. diagnostic procedures | |
39 | Disability assessment-physical | |
3A | Disability assessment - mental | |
3B | Biopsy admin | |
3C | Exhaled nitric oxide test | |
3Z | Diagnostic procedure NOS | |
4. | Laboratory procedures | |
41 | Laboratory procedures -general | |
42 | Haematology | |
43 | Immunology | |
44 | Blood chemistry | |
45 | Chemical function tests | |
46 | Urine examination | |
47 | Examination of faeces | |
48 | Cerebro-spinal fluid exam. | |
49 | Semen examination | |
4A | Vomit examination | |
4B | Synovial fluid examination | |
4C | Bone marrow examination | |
4D | Pleural fluid examination | |
4E | Sputum examination | |
4F | Ascitic fluid examination | |
4G | Calculus examination | |
4H | Amniotic fluid examination | |
4I | Miscellaneous samples | |
4J | Microbiology | |
4K | General pathology | |
4L | Genetic observations | |
4M | Tumour staging | |
4N | Dialysis fluid examination | |
4P | Saliva examination | |
4Q | Generic biochemistry levels | |
4Z | Laboratory procedure NOS | |
5. | Radiology/physics in medicine | |
51 | Radiology/physics - general | |
52 | Plain radiography | |
53 | Soft tissue imaging - plain | |
54 | Contrast radiography excl.CVS | |
55 | Cardiovascular sys.angiography | |
56 | Other X-ray diagn. procedures | |
57 | Diagnostic nuclear medicine | |
58 | Physics: other diagn. methods | |
59 | External radiotherapy | |
5A | Other nuclear therapy | |
5B | Physics - other therapy | |
5C | Imaging interpretation | |
5Z | Radiology/physics NOS | |
6. | Preventive procedures | |
61 | Contraception | |
62 | Patient pregnant | |
63 | Birth details | |
64 | Child health care | |
65 | Infectious dis:prevent/control | |
66 | Chronic disease monitoring | |
67 | Counselling/health education | |
68 | Screening | |
69 | Special examinations | |
6A | Patient reviewed | |
6B | Health promotion | |
6C | Primary prevention | |
6D | Secondary prevention | |
6E | Accident prevention | |
6F | Stroke prevention | |
6G | Postnatal care | |
6H | Brief intervention | |
6Z | Preventive procedures NOS | |
7. | Operations, procedures, sites | |
70 | Nervous system operations | |
71 | Endocrine system and breast operations | |
72 | Eye operations | |
73 | Ear operations | |
74 | Respiratory tract operations | |
75 | Mouth operations | |
76 | Upper digestive tract operations | |
77 | Lower digestive tract operations | |
78 | Other abdominal organ operations | |
79 | Heart operations | |
7A | Artery and vein operations | |
7B | Urinary operations | |
7C | Male genital organ operations | |
7D | Lower female genital tract operations | |
7E | Upper female genital tract operations | |
7F | Obstetric operations | |
7G | Skin operations | |
7H | Soft tissue operations | |
7J | Skull or spine, bone and joint operations | |
7K | Other bone and joint operations | |
7L | Miscellaneous operations | |
7M | Subsidiary classification of methods of operation | |
7N | Subsidiary classification of laterality and operation sites | |
7P | Diagnostic imaging, testing and rehabilitation | |
7Q | Drugs | |
8. | Other therapeutic procedures | |
81 | Removal of unwanted material | |
82 | Correction of misplacement | |
83 | Immobilisation and support | |
84 | Planned procedure | |
85 | Other mechanical procedures | |
86 | Other physical agent therapy | |
87 | Respiratory procedures | |
88 | Cardiovascular procedures | |
89 | Pre/post-operative procedures | |
8A | Monitoring of patient | |
8B | Other therapy | |
8C | Other care | |
8D | Anatomo-physiolog. assistance | |
8E | Physiotherapy/remedial therapy | |
8F | Other rehabilitation | |
8G | Psychotherapy/sociotherapy | |
8H | Referral for further care | |
8I | Procedure not carried out | |
8J | Radiotherapy treatment groups | |
8K | Body surface points | |
8L | Operative procedures planned | |
8M | Patient requested procedure | |
8N | Environmental adaptation | |
8O | Provision of services and equipment | |
8P | Removal of surgical material and sutures | |
8Q | Behaviour management | |
8R | Use of foot impulse device | |
8S | Use of intermittent pneumatic compression device | |
8T | Referral - additional | |
8V | Admission procedure | |
8W | Referral statuses | |
8Z | Other therapy procedure NOS | |
9. | Administration | |
91 | Patient registration | |
92 | Patient de-registration | |
93 | Patient record types | |
94 | Death administration | |
95 | Maternity services admin. | |
96 | Contraceptive claims | |
97 | Immunisation claims | |
98 | Other items of service admin. | |
99 | Ancillary staff administration | |
9A | Rent and rates payments | |
9B | Supply of drugs payment admin | |
9C | Training/seniority/leave admin | |
9D | Certificates - administration | |
9E | Medical examinations/reports | |
9F | Child examn/reports/meetings | |
9G | Notifications | |
9H | Mental health administration | |
9I | Practice supplies admin. | |
9J | Drug stock control admin. | |
9K | Forms - miscellaneous | |
9L | Accounting administration | |
9M | Audit administration | |
9N | Patient encounter admin. data | |
9O | Prevention/screening admin. | |
9P | Clinical trial administration | |
9Q | Research administration | |
9R | Patient misc. admin. data | |
9S | Ethnic groups (census) | |
9T | Ethnicity and other related nationality data | |
9U | Complaints about care | |
9V | Bill/Fee administration | |
9W | Power of attorney | |
9X | Advanced directive administration | |
9Y | Further opinion sought | |
9Z | Administration NOS | |
9a | Explanation of practice procedure | |
9b | Record transfer administration | |
9c | Context values | |
9d | Relative | |
9e | GP out of hours service administration | |
9f | History taking administration | |
9g | Significant event audit | |
9h | Exception reporting: GP contract quality indicators | |
9i | Ethnic category - 2001 census | |
9j | Risk management administration | |
9k | Enhanced services administration | |
9l | Patient record status | |
9m | Prevention/screening administration - additional | |
9n | Practice based commissioning administration | |
9o | Walk in centre administration | |
9p | Medication monitoring administration | |
9q | Consent status | |
9r | Information gathering | |
9s | Drug misuse clinic administration | |
9t | Ethnic category - 2011 census | |
A. | Infectious and parasitic diseases | |
A0 | Intestinal infectious diseases | |
A1 | Tuberculosis | |
A2 | Zoonotic bacterial diseases | |
A3 | Other bacterial diseases | |
A4 | Poliomyelitis and other non-arthropod-borne viral diseases of central nervous system | |
A5 | Viral diseases with exanthem | |
A6 | Arthropod-borne viral diseases | |
A7 | Other viral and chlamydial diseases | |
A8 | Rickettsioses and other arthropod-borne diseases | |
A9 | Syphilis and other venereal diseases | |
AA | Other spirochaetal diseases | |
AB | Mycoses | |
AC | Helminthiases | |
AD | Other infectious and parasitic diseases | |
AE | Late effects of infectious and parasitic diseases | |
Ay | Other specified infectious or parasitic diseases | |
Az | Infectious and parasitic diseases NOS | |
B. | Neoplasms | |
B0 | Malignant neoplasm of lip, oral cavity and pharynx | |
B1 | Malignant neoplasm of digestive organs and peritoneum | |
B2 | Malignant neoplasm of respiratory tract and intrathoracic organs | |
B3 | Malignant neoplasm of bone, connective tissue, skin and breast | |
B4 | Malignant neoplasm of genitourinary organ | |
B5 | Malignant neoplasm of other and unspecified sites | |
B6 | Malignant neoplasm of lymphatic and haemopoietic tissue | |
B7 | Benign neoplasms | |
B8 | Carcinoma in situ | |
B9 | Neoplasms of uncertain behaviour | |
BA | Unspecified nature neoplasm | |
BB | [M]Morphology of neoplasms | |
BC | Polyp | |
By | Neoplasms otherwise specified | |
Bz | Neoplasms NOS | |
C. | Endocrine, nutritional, metabolic and immunity disorders | |
C0 | Disorders of thyroid gland | |
C1 | Other endocrine gland diseases | |
C2 | Nutritional deficiencies | |
C3 | Other metabolic and immunity disorders | |
Cy | Other specified endocrine, nutritional, metabolic or immunity disorders | |
Cz | Endocrine, nutritional, metabolic or immunity disorder NOS | |
D. | Diseases of blood and blood-forming organs | |
D0 | Deficiency anaemias | |
D1 | Haemolytic anaemias | |
D2 | Aplastic and other anaemias | |
D3 | Clotting and bleeding disorders | |
D4 | White blood cell and other blood disorders | |
Dy | Other specified disorders of blood or blood forming organ | |
Dz | Blood/blood forming organ NOS | |
E. | Mental disorders | |
E0 | Organic psychotic conditions | |
E1 | Non-organic psychoses | |
E2 | Neurotic, personality and other nonpsychotic disorders | |
E3 | Mental retardation | |
Eu | [X]Mental and behavioural disorders | |
Ey | Other specified mental disorders | |
Ez | Mental disorders NOS | |
F. | Nervous system and sense organ diseases | |
F0 | Inflammatory diseases of the central nervous system | |
F1 | Hereditary and degenerative diseases of the central nervous system | |
F2 | Other central nervous system disorders | |
F3 | Peripheral nervous system disorders | |
F4 | Disorders of eye and adnexa | |
F5 | Diseases of the ear and mastoid process | |
Fy | Other specified diseases of nervous system or sense organ | |
Fz | Nervous system or sense organ disease NOS | |
G. | Circulatory system diseases | |
G0 | Acute rheumatic fever | |
G1 | Chronic rheumatic heart disease | |
G2 | Hypertensive disease | |
G3 | Ischaemic heart disease | |
G4 | Pulmonary circulation diseases | |
G5 | Other forms of heart disease | |
G6 | Cerebrovascular disease | |
G7 | Arterial, arteriole and capillary disease | |
G8 | Vein, lymphatic and circulatory diseases NOS | |
G9 | Vascular calcification | |
GA | Rheumatic heart disease | |
GB | Hereditary angiopathy with nephropathy, aneurysms and muscle cramps syndrome | |
Gy | Other specified diseases of circulatory system | |
Gz | Circulatory system disease NOS | |
H. | Respiratory system diseases | |
H0 | Acute respiratory infections | |
H1 | Other upper respiratory tract diseases | |
H2 | Pneumonia and influenza | |
H3 | Chronic obstructive pulmonary disease | |
H4 | Lung disease due to external agents | |
H5 | Other respiratory system diseases | |
Hy | Other specified diseases of respiratory system | |
Hz | Respiratory system diseases NOS | |
J. | Digestive system diseases | |
J0 | Oral cavity, salivary glands and jaw diseases | |
J1 | Oesophageal, stomach and duodenal diseases | |
J2 | Appendicitis and other disorders of the appendix | |
J3 | Hernia of abdominal cavity | |
J4 | Noninfective enteritis and colitis | |
J5 | Other diseases of the intestines and peritoneum | |
J6 | Liver, biliary, pancreas + gastrointestinal diseases NEC | |
Jy | Other specified diseases of digestive system | |
Jz | Digestive system diseases NOS | |
K. | Genitourinary system diseases | |
K0 | Nephritis, nephrosis and nephrotic syndrome | |
K1 | Other urinary system diseases | |
K2 | Male genital organ diseases | |
K3 | Disorders of breast | |
K4 | Female pelvic inflammatory diseases | |
K5 | Other female genital tract disorders | |
Ky | Other specified diseases of genitourinary system | |
Kz | Genitourinary disease NOS | |
L. | Complications of pregnancy, childbirth and the puerperium | |
L0 | Pregnancy with abortive outcome | |
L1 | Pregnancy complications | |
L2 | Risk factors in pregnancy | |
L3 | Complications occurring during labour and delivery | |
L4 | Complications of the puerperium | |
L5 | Maternal care for fetus | |
Ly | Other specified complications of pregnancy, childbirth or the puerperium | |
Lz | Complications of pregnancy, childbirth and the puerperium NOS | |
M. | Skin and subcutaneous tissue diseases | |
M0 | Skin and subcutaneous tissue infections | |
M1 | Other skin and subcutaneous tissue inflammatory conditions | |
M2 | Other skin and subcutaneous tissue disorders | |
My | Other specified diseases of skin or subcutaneous tissue | |
Mz | Skin and subcutaneous tissue disease NOS | |
N. | Musculoskeletal and connective tissue diseases | |
N0 | Arthropathies and related disorders | |
N1 | Vertebral column syndromes | |
N2 | Rheumatism, excluding the back | |
N3 | Osteopathies, chondropathies and acquired musculoskeletal deformities | |
Ny | Other specified diseases of musculoskeletal or connective tissue | |
Nz | Musculoskeletal and connective tissue diseases NOS | |
P. | Congenital anomalies | |
P0 | Anencephalus and similar anomalies | |
P1 | Spina bifida | |
P2 | Other nervous system congenital anomalies | |
P3 | Congenital eye anomalies | |
P4 | Ear, face and neck congenital anomalies | |
P5 | Bulbus cordis and cardiac septal closure anomalies | |
P6 | Other congenital heart anomalies | |
P7 | Other congenital circulatory system anomalies | |
P8 | Respiratory system congenital anomalies | |
P9 | Cleft palate and lip | |
PA | Other congenital upper alimentary tract anomalies | |
PB | Other congenital digestive system anomaly | |
PC | Congenital genital organ anomalies | |
PD | Urinary system congenital anomalies | |
PE | Certain congenital musculoskeletal deformities | |
PF | Other congenital limb anomalies | |
PG | Other congenital musculoskeletal anomalies | |
PH | Congenital integument anomalies | |
PJ | Chromosomal anomalies | |
PK | Other and unspecified congenital anomalies | |
Py | Other specified congenital anomaly | |
Pz | Congenital anomaly NOS | |
Q. | Perinatal conditions | |
Q0 | Fetus or neonate affected by maternal problem unrelated to pregnancy | |
Q1 | Disorders due to slow fetal growth, low and high birthweight | |
Q2 | Birth trauma, asphyxia and hypoxia | |
Q3 | Fetus and newborn respiratory conditions | |
Q4 | Other perinatal conditions | |
Qy | Other specified perinatal conditions | |
Qz | Perinatal conditions NOS | |
R. | [D]Symptoms, signs and ill-defined conditions | |
R0 | [D]Symptoms | |
R1 | [D]Nonspecific abnormal findings | |
R2 | [D]Cause of morbidity and mortality unsure and ill-defined | |
R3 | [D]Specific abnormal findings | |
Ry | [D]Other specified symptoms, signs or ill-defined conditions | |
Rz | [D]Symptoms, signs and ill-defined conditions NOS | |
S. | Injury and poisoning | |
S0 | Fracture of skull | |
S1 | Fracture of neck and trunk | |
S2 | Fracture of upper limb | |
S3 | Fracture of lower limb | |
S4 | Dislocations and subluxations | |
S5 | Sprains and strains of joints and adjacent muscles | |
S6 | Intracranial injury excluding those with skull fracture | |
S7 | Internal injury of chest, abdomen and pelvis | |
S8 | Open wound of head, neck and trunk | |
S9 | Open wound of upper limb | |
SA | Open wound of lower limb | |
SB | Injury to blood vessels | |
SC | Late effects of injury, poisoning, toxic effects and other external causes | |
SD | Superficial injury | |
SE | Contusion (bruise) with intact skin | |
SF | Crushing injury | |
SG | Foreign body (FB) in orifice | |
SH | Burns | |
SJ | Nerve and spinal cord injuries | |
SK | Traumatic complications and unspecified injuries | |
SL | Poisoning | |
SM | Nonmedicinal agent causing toxic effects | |
SN | Other and unspecified external effect causes | |
SP | Surgical and medical care complications NEC | |
SQ | Open wounds involving multiple body regions | |
SR | Injury involving multiple body regions | |
SS | Accidental injury | |
Sy | [X] Injury and poisoning classification terms | |
Sz | Injury and poisoning NOS | |
T. | Causes of injury and poisoning | |
T0 | Railway accidents | |
T1 | Motor vehicle traffic accidents (MVTA) | |
T2 | Motor vehicle non-traffic accident, MVNTA | |
T3 | Other road vehicle accidents | |
T4 | Water transport accidents | |
T5 | Air and space transport accidents | |
T6 | Vehicle accidents not elsewhere classifiable | |
T7 | Place of occurrence of accident or poisoning | |
T8 | Accidental poisoning by drugs, medicines and biologicals | |
T9 | Accidental poisoning by other solid and liquid substances, gases and vapours | |
TA | Medical accidents to patients during surgical and medical care | |
TB | Medical and surgical procedures as the cause of abnormal reaction of patient or later complication, without mention of misadventure at the time of procedure | |
TC | Accidental falls | |
TD | Accidents caused by fire and flames | |
TE | Accidents due to natural and environmental factors | |
TF | Accidents caused by submersion, suffocation and foreign bodies | |
TG | Other accidents | |
TH | Late effects due to accidental injury | |
TJ | Drugs, medicines and biological substances causing adverse effects in therapeutic use | |
TK | Suicide and selfinflicted injury | |
TL | Homicide and injury purposely inflicted by other persons | |
TM | Legal intervention causing injury | |
TN | Injury undetermined whether accidentally or purposely inflicted | |
TP | Injury resulting operations of war | |
Tz | Causes of injury and poisoning NOS | |
U. | [X]External causes of morbidity and mortality | |
U0 | [X]Transport accidents | |
U1 | [X]Other external causes of accidental injury | |
U2 | [X]Intentional self-harm | |
U3 | [X]Assault | |
U4 | [X]Event of undetermined intent | |
U5 | [X]Legal intervention and operations of war | |
U6 | [X]Complications of medical and surgical care | |
U7 | [X]Sequelae of external causes of morbidity and mortality | |
U8 | [X]Supplementary factors related to causes of morbidity and mortality classified elsewhere | |
Z. | Unspecified conditions | |
ZV | [V]Factors influencing health status and contact with health services | |
Zw | [Q] Temporary qualifying terms |
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