Regular audit of coded clinical data, associated processes and documentation enables:

• users to have confidence in data quality,
• provide necessary information to make relevant changes and
• achieve continuous quality improvement.

The current version of the Clinical Coding Audit Methodology developed and maintained by the NHS Classifications Service is at the heart of the Audit Commission clinical coding Data Assurance Framework programme. The pressure on any clinical coding auditor working in the NHS to have the correct training, knowledge and tools has increased so we have compiled the supporting information below as it is in the interests of the NHS to ensure:

• that audit and auditors are of the highest professional standard,
• conversant with current technical coding standards and
• in a position to be fair and objective when ensuring conformance to coding standards.

Any clinical coder auditor working in the NHS sector must have the correct tools, knowledge and training to undertake this role to ensure that coded clinical data adhering to national standards are accurately and consistently monitored and therefore comparable across time and between sources.

It is not enough that clinical coding auditors have excellent clinical coding skills and have attained ACC status and they also need superior report writing and interpersonal skills.

Core curriculum for clinical coding auditors

Those career coders wishing to train as auditors must have completed all components of the clinical coder's toolbox which is the minimum training acquired before being considered an auditor. In addition, he or she must have:

• Attained Accredited Clinical Coder Status (ACC) by passing the National Clinical Coding Qualification(UK)
• Have proven report-writing skills by providing evidence of successful completion of a report writing course and details of any subsequent experience.
• Successfully completed the national Clinical Coding Auditor Programme. Read an introduction, check the schedule and apply.
• Signed up to the Code of Practice for clinical coding auditors.
  

Clinical coding auditing tools

All the tools in the Clinical Coder's Toolbox section are relevant to auditors. Plus:

• Clinical Coding Audit Methodology which is available ONLY to all those that successfuly complete the CCAP. A summary guide is available (PDF, 144Kb).
• Code of Conduct for clinical coding auditors available to those that attend the audit workshop.
• Local Trust policy and procedure document relating to clinical coding. These vary from organisation to organisation as an essential management tool. Read our guide to policies and procedures.
• How an auditor maintains status.
• Chapter Z Error Key assignments and further guidance on this complex area.

Supporting information

• Data Protection Act 1988. Read more.
• The implications of financial reforms in the NHS (including Payment by Results using Healthcare Resource Groups). Read more about Healthcare Resource Groups.
• Information Governance Toolbox.
• NHS Data Model and Dictionary.
• The Audit Commission Payment by Results data assurance framework.

Further tools

Below are links to other relevant external websites.

• Health Informatics careers in the NHS.
• UK Council for Health Informatics Professionals (UKCHIP).
• Association for ICT Professionals in Health and Social Care (ASSIST).
• Institute of Health Record and Information Management (IHRIM).