RCGP coding guidance

The following coding guidance has been released by the RCGP and is replicated here for convenience. In addition, data entry templates have also been developed for your use.


Coding guidance as of 13 March 2020

‘In early February, new terms were added to all general practice computerised medical record (CMR) systems so that data relevant to COVID-19 can be recorded. Practices are asked to use these to code in the practice’s CMR system:

  • Confirmed cases where there is hard evidence of infection, for example, a positive test or discharge summary
  • Exposure to another case with COVID-19
  • Suspected cases perhaps where a patient has travelled to an area of high risk
  • Patients referred for COVID-19 testing
  • Record where COVID-19 has been excluded, for example, negative test results.

The new terms available are listed in the table below – their names were set before 2019-nCoV (Wuhan) was renamed COVID-19.’

Skin symptoms and possible causes
Category Code
Definite case Confirmed 2019-nCoV (Wuhan) infection
Possible case Exposure to 2019-nCoV (Wuhan) infection
Suspected 2019-nCoV (Wuhan) infection
Tested for 2019-nCoV (Wuhan) infection
Not a case Excluded 2019-nCoV (Wuhan) infection

Summary

External Resources

Date Published Article Format Author(s)
13 March 2020 RCGP COVID-19: Next steps in primary care surveillance Online article Professor Simon de Lusignan
13 March 2020 RCGP COVID-19: Next steps in primary care surveillance Online article Professor Simon de Lusignan
April 2020 Faculty of Clinical Informatics COVID-19 coding - a starter guide Webinar Faculty of Clinical Informatics

Page last reviewed: 3 April 2020
Next review due: 3 July 2020
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