Record & code

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Ensure individuals are assessed and coded for the condition being treated.

Code individuals’ records appropriately to enable and support proactive medication reviews and follow up in the short and long-term in primary and secondary care.

Only a minority of individuals currently have a clear electronically recorded Read Coded indication or reason for receiving an antidepressant.(73)

Although the indication for antidepressant use can be identified from free text entries in electronic and paper clinical notes, these are not easily identified unless an individual’s clinical records are accessed and specifically searched.(74)  Prescribers have indicated that in consequence:

‘...patients can get lost in the system, and that systems which adequately prompt medication reviews would be useful in broaching discontinuation with patients.’ (75)

At time of publication of this guideline, primary care practices use Read codes. Be aware that the strategy is to move to SNOMED CT codes in future.

Examples of key Read codes:

Depression

  • Depression - code E2B
  • Anxiety with depression - E2003
  • Bipolar affective disorder - Eu32

Pain

  • Chronic pain - 1M52
  • Neuropathic pain- N2423
  • Diabetic neuropathic pain - 1M8
  • Record chronic pain review as 66n

Anxiety disorder

  • Generalised anxiety disorder (GAD) - E2002
  • Post-traumatic stress disorder (PTSD, Eu431)

Where the condition has resolved and the antidepressant has been stopped, please use the appropriate Read code where possible, e.g. depression resolved (212S), anxiety resolved (2126J). Note that other Read Codes for resolution of symptoms are not currently available on General Practice systems.

In relation to mental health and emotional distress, where appropriate, complete and record a bio-psycho-social assessment including assessment of risk of self-harm and suicide, and record the severity, as outlined in appropriate guidelines.(7,10)

Consider: alcohol (FAST tool), substance misuse, bereavement, and exclude organic disease or causes of symptoms. 

Use and record assessment tools such as PHQ-9, CORE 10 or other suitable tool, to support continuity of care.