Suggested Read Codes for Documenting Risk in Children and Young People
DOMESTIC SITUATIONRelevant history/cause for concern / Read code/term / Whose record? / Free-text (information to be entered attached to the read code)
Family composition / ZU Family details and housing composition / Every child where there are concerns / Note who lives with the child, including information on ‘other households’ if child spends significant periods of time spent away from home e.g. at father’s house
Housing / 13E Inadequate housing / Every child where housing is substandard / Note what is ‘inadequate’ e.g. lack of space or heat, prone to vandalism, multiple occupancy, damp, infested etc.
Violence in the home / 14X3 History of domestic violence / Every adult who has perpetrated/ allegedly perpetrated DV / Note the nature of the violence (including if children were present)
14X8 Victim of domestic violence / Every adult or child who has been a victim of DV / Note the nature of the violence and who the (alleged) perpetrator was
13VF At risk violence in the home / Every relevant child record / Note who (allegedly) perpetrated the violence, the nature of it, and whether children were present
School situation / ZP8 School attendance / Every relevant child record / Enter school attended and any relevant issues e.g. bullying/school refusal etc;
HISTORY OF ABUSE
Relevant history/cause for concern / Read code/term / Whose record? / Free-text (information to be entered attached to the read code)
Child abuse / 14X History of abuse / Every relevant adult record / Note the nature of the abuse and who it was directed towards
13W3 child abuse in the family / Every relevant child record, including any other children in the close family/ household of the index case / Note the nature of the abuse and the relationship of any children to the index case
PARENTAL ILLNESS/CAUSES OF CONCERN
(‘parent’ might imply any adult in the wider ‘household’ who has a significant amount of contact with the child e.g. grandparents/mother’s boyfriend etc)
Relevant history/cause for concern / Read code/term / Whose record? / Free-text (information to be entered attached to the read code)
Parental mental illness / E…. mental disorders (virtually all read codes in the hierarchy) / Every relevant adult record / History of substance misuse is particularly relevant
Parent with mental illness / 128Z FH: mental disorder NOS / Every relevant child record / Note the relationship of the child to the individual with the mental disorder, and the nature of that disorder
Parental drug misuse / 1283 FH: drug dependency / Every relevant child record / Note the relationship of the child to the individual with the drug misuse problem
Learning difficulties / 13Z4E Learning difficulties / Every relevant record
Parent with learning difficulties / 12W1 FH: learning difficulties / Every relevant child record / Note the relationship of the child to the individual with learning difficulties
Parental alcohol problem / 1282 FH: alcoholism / Every relevant child record / Note the relationship of the child to the individual with the alcohol problem
Adult on sex offenders register / 14X4 on sex offenders register / The relevant adult record
Antenatal care risk identified / 625 A/N care: social risk / Every relevant maternal record / Note the nature of the risk e.g. poor housing, history of poor A/N attendance, late booking etc
Any other concerns / 9FZ Child exam/report NOS / Every relevant child record / Any other concern that might not of its own be significant but that may be part of a pattern of events e.g. an unexplained bruise
SOCIAL SERVICES CASE CONFERENCE OUTCOMES
Relevant history/cause for concern / Read code/term / Whose record? / Free-text (information to be entered attached to the read code)
Social services conference / 3875 social services case conference / Every relevant child record
The child protection register
The child protection register (continued) / 13IM child on protection register / Every relevant child record / Note the category of risk and whether the registration has been ‘added’ or ‘maintained’
13IO child removed from protection register / Every relevant child record
13IN family member on protection register / Every child in the close family/household of the index case / Note the relationship of the child to the family member
13IN family member removed from protection register / Every child in the close family/household of the index case / Note the relationship of the child to the family member
The ‘at risk’ category identified at conference / 13ZT At risk of physical abuse / Every relevant child record
13ZW At risk of sexual abuse / Every relevant child record
13ZR At risk of emotional abuse / Every relevant child record
13ZV At risk of neglect / Every relevant child record
Child not put on protection register / 64c Child protection procedure / Every relevant child record / freetext ‘Not registered’
Registration decision deferred / 64c Child protection procedure / Every relevant child record / freetext ‘Registration decision deferred’
RISK ASSESSMENT
Relevant history / Read code/term / Whose record? / Free-text (information to be entered attached to the read code)
Concern shared with others / Z4A Discussion / Every relevant child record / Note who the concern was discussed with and the outcome
Child referred to social services / 8HHB Referral to social services / Every relevant child record / Note who the referral made to and the agreed plan
Dr D W Jones
Newcastle PCT May 2007
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