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Clinical Coding Audit

The need for clinical coding audit

Clinical coding is the process whereby the care given to a patient (usually the diagnostic and procedure information) recorded in the patient notes is translated into coded data (ICD-10 and OPCS-4) and entered into the hospital information system.

Clinical coding staff depend on clear, accurate source information in order to produce a true picture of hospital activity and the care given by clinicians. The coded data is important for a whole range of purposes such as:

  • Monitoring provision of health services across the UK
  • Research and monitoring of health trends
  • NHS financial planning and Payment by Results
  • Local and national clinical coding audit
  • Clinical governance.

The quality of the data to accurately reflect your hospital activity depends on:

  • clear, accurate and timely information provided in the patient notes;
  • accurate and consistent clinical coding; and
  • good management processes surrounding its collection and processing such as policy and procedures, investment in training and accreditation.

Data validated and audited is most likely to be recognised as a true reflection of hospital activity so establishing regular clinical coding internal audits at your trust ensures a robust data quality cycle.

Clinical coding audit is also an integral part of:

For more information on clinical coding audit visit: