This unit describes the skills and knowledge to participate actively in internal and external audits of clinical coding to evaluate, validate and correct own work and contribute to audit review processes.  This unit applies to those with responsibility for interpreting and extracting patient clinical information for the purposes of clinical coding. Work may be performed as an individual or as part of team under limited supervision.

Unit details

Study level:
Vocational and further education (TAFE)
Unit code:


Assessment tasks will be designed to reinforce and extend knowledge and skill competence within set and controlled parameters in accordance with each unit's learning outcomes and performance criteria requirements, including the setting of work based practical application tasks designed to provide evidence of competence outcomes, within periodic and scheduled timelines. Students will be expected to demonstrate the following required skills: - analytical skills to: evaluate the appropriateness of the assigned AR-DRG; recognise and seek clarification of audit issues; - communication skills to: participate in formal and informal meetings; provide feedback to managers/supervisors on issues such as the completeness of clinical documentation; numeracy skills to quantify the impact of classification errors including the calculation of % error rate; - self management skills to: perform work according to organisational procedures and protocols; participate actively and responsively in internal and external audits; act on audit results and feedback; digital technology skills to access and use relevant computer programs, and; - digital literacy skills to navigate computer based programs.Students will also be expected to demonstrate the following knowledge: - factors that impact on classification allocation including the impact of specific diagnosis and/or intervention codes to enable participation in audits; - purposes of internal and external audits to enable appropriate participation; - organisational procedures and protocols for: accessing, using, securing and releasing data; resolving coding issues, and; communicating with colleagues and clinicians.

Where to next?

As part of a course

This unit is studied as part of the following courses. Refer to the course page for information on how to apply for the course.

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