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Clinical Coding Audit Programme

 

Digital Health and Care Wales (DHCW)’ national clinical coding audit programme has the overall aim of assessing and supporting the improvement in clinical coding accuracy across NHS Wales. Welsh Coding departments are required to satisfy Welsh Government standards on completeness, timeliness, and accuracy of coded data as outlined in the NHS Wales Delivery Framework.

 

The programme was established following the completion of an initial all-Wales audit of clinical coding accuracy that was undertaken in collaboration with the Wales Audit Office in 2013/14. The programme intends to identify areas of improvement or non-improvement following the recommendations given in those (and subsequent) audits.

 

This work is being taken forward by the DHCW Clinical Classifications Team and will ensure a continual ongoing programme of clinical coding accuracy audit across all Welsh Health Boards and NHS Trusts.

 

Individual reports are published at Health Board level, outlining the findings and recommendations of the DHCW Clinical Classifications Team’s audit of clinical coding accuracy.

 

Aims and Objectives

The audit programme aims to assess the accuracy of the clinically coded data produced by individual Health Boards by comparing the codes assigned by the clinical coding department against national clinical coding standards.

 

Each audit results in a report which aims to provide a benchmark that can be used by the clinical coding department to identify areas for improvement within the organisation and aid in the identification and planning of future training needs. Conclusions and recommendations based on areas of both good and poor practice found are provided to achieve this.

 

The audit report also aims to evaluate the quality of the source documentation used by the coders and the local policies and procedures used at each organisation.

 

The objectives for the audit programme are:

  • To assess the clinical coding data against national clinical coding standards;

  • To identify and report areas of good and bad practice;

  • To review and assess the accuracy of the source documentation used for clinical coding;

  • To assess the level of clinical involvement with the coding department and to what degree this impacts on the coding process and coding accuracy;

  • To make recommendations designed to support future improvement in the accuracy of clinically coded data within the UHB or Trust;

  • To highlight training issues within the department.

 

If you have any questions about the audit programme, please direct them to Helen Dennis ACC or Karen Windsor ACC, the National Clinical Coding Audit Programme Leads, via the clinical coding helpdesk: clinical.coding@wales.nhs.uk.