Monthly Coding Audit Summary Report

Facilities are encouraged to use the monthly audit form on the UBU website for completing the Monthly Data Quality Commander’s Statement.  On the Monthly Coding Audit Summary Report, identify the number of records requested and the number of records received from the facility.

•    Identify the number of records received containing encounter documentation for the encounter.
•    Document the number of records with illegible documentation.
•    Document the number of records with use of non-approved abbreviations or acronyms. 

Abbreviations and acronyms are considered approved for this audit if the term is completely spelled out initially with the abbreviation listed afterwards, if the term is on the approved list of MTF abbreviations or if the term is in the DoD list of approved abbreviations