This page contains information and training resources regarding the use, application and analysis of clinical coding systems used in Scotland. This includes both Terminologies and Classifications.
This page is currently under construction and more content will continue to be added as it becomes available.
What is Clinical Coding?
Clinical Coding is ‘The translation of medical terminology as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention into a coded format which is nationally and internationally recognised.' World Health Organization (WHO).
- It includes both Classifications and Terminologies which are each important and used for different purposes.
- The current Classifications used in NHS Scotland are ICD-10v5 and OPCS4.10.
- The current Terminology used in GP Practice is Read. This is currently transitioning to SNOMED-CT.
What is it used for?
Coded data is used for a range of purposes, including:
- Audit
- Epidemiology
- Research
- Clinical governance
- Data entry and transfer
- And much more
Useful Links
We have provided some links to other websites which contain helpful information regarding the topics covered within this page.
Clinical Coding for Clinicians
This module provides an overview of Clinical Coding using Classifications (ICD and OPCS) and their purpose. It is aimed at Secondary Care Clinicians and provides information on the Clinical Coding process as well as how data quality can be improved through clear and consistent discharge letters.
Read Coding
Read is the current Terminology used in General Practice. This video contains information about Read codes including structure, hierarchy and code selection.
