A review of Clinical Terms Version 3 (Read Codes) for speech and language record keeping.

There may be bugs, there may be viruses, but computers are here to stay. Access to computers may vary greatly from 'seen one once' to daily usage. However, with an increasing dependence on electronic records, even the most remote therapist will ultimately be faced with computerization. To make this process as painless as possible some commonality in approach is logical. A common vocabulary, for instance, would ensure that dysphasia in Cape Town is the same as dysphasia in Dundee. This is great in theory but is Clinical Terms Version 3 (Read Codes) (CTV3) sufficient to encode records in clinical practice? It is to this end that the Speech and Language Therapy Department at Burton Hospital took part in a multidisciplinary project with the NHS Centre for Coding and Classification (NHS CCC). (NHS CCC became the NHS Information Authority, Coding and Classification on 1 April 1999.) Their CTV3 offers a standardized clinical terminology. An audit of patient case-notes found that 78% of the terms used by therapists were available in CTV3. Although there are many issues raised concerning electronic patient records, CTV3 presented as a potential vocabulary for recording patient information in this acute setting.