Global

Clinical documentation and coding standards

A ready-made course you customise for your organisation, with a live session deck and two surveys. You only add the 14 details that are specific to your organisation.

See the live deckSee the full outline
Try the coursePreview the survey
Length
50 min
Lessons
6 lessons
Frequency
At induction
Last reviewed
21 Oct 2026
Course preview
Interactive course

Scenarios, sorting activities and quizzes with feedback on every answer.

What's included

Three pieces that work together

Copy once, get everything. Learners prepare on their own, you answer questions live, and the surveys tell you what stuck.

Self-paced course

Short lessons with real workplace scenarios, not walls of text.

  • 6 lessons, about 50 minutes
  • Flashcards, scenario, sorting activity, tabs and quizzes
  • 1-question final check, 80% to pass

Live session deck

An AhaSlides presentation to run after the course, in person or online.

  • 11 slides
  • Word cloud, open-ended slides
  • A closing slide for your contacts

Two surveys

Find out what landed, and whether people use it on the job.

  • Post-course feedback, about 2 minutes
  • 30-day check-in
  • Anonymous by default
  • Results feed your next refresher

Learning objectives

At the end of this course, learners can

Each objective and the lesson that covers it.

IDObjectiveSourceWhere it's covered
TO 156.0Achieve ≥ 80% on the final assessment-Whole course
LO 156.1.1Describe what makes a clinical record entry complete, accurate and timelyNMC Code s10; NHS England NCCS 2026; ICD-10-CM Guidelines FY 2027Lesson 1: What good documentation looks like
LO 156.2.1Find and assign a diagnosis code at the right level of detail using the index and tabular list + your infoICD-10-CM Guidelines FY 2027 Section I; NHS England NCCS 2026Lesson 2: ICD and procedure coding basics
LO 156.3.1Decide when comorbidities, complications and uncertain diagnoses can be coded under US and England rulesICD-10-CM Guidelines FY 2027 Sections I-IV; NHS England NCCS DGCS.2, DGCS.3, DCS.XIX.7Lesson 3: Coding complications and comorbidities
LO 156.4.1Write a compliant, non-leading query and take part in coding audit + your infoACDIS/AHIMA Compliant Query Practice; NHS England NCCS 2026Lesson 4: Record-keeping law and audit
LO 156.5.1Spot and correct common documentation and coding errorsAll of the aboveLesson 5: Common errors

Your part: what a template can't do for you

  • Your workplace details: fill in the 14 highlighted fields so the course describes your own policies, contacts and locations.
  • Records: record completion in your own LMS or record system.

Course outline

6 lessons, about 50 minutes

Minutes per lesson are an estimate, shared out by page count.

ContentInteractiveVideoYou customise
1

What good documentation looks like

3 pages

10 min
Before you beginNoteYour infoList
The record drives the codeTextFlashcardsQuiz
Rate the entryTextSorting activityNoteYour infoYour info
2

ICD and procedure coding basics

3 pages

10 min
Which classification, which version?TextYour infoTabsQuiz
Finding the full codeNoteStep-by-stepQuiz
Which diagnosis comes first?TextScenario
3

Coding complications and comorbidities

3 pages

9 min
ComorbiditiesTextAccordionMulti-select quiz
ComplicationsTextTabsScenario
Uncertain diagnosesTextYour infoTableFlashcardsQuiz
4

Record-keeping law and audit

2 pages

6 min
Asking the clinicianTextSorting activityQuiz
Keeping records, and coding auditTextYour infoProcessYour infoQuiz
5

Common errors

2 pages

6 min
Spot the errorTextYour infoFlashcards
Code-the-case practiceScenarioQuiz
6

Final assessment

3 pages

9 min
Final assessment, part 1Quiz
Final assessment, part 2Quiz
CompletionKey factListNoteYour infoButtonYour info

Live deck and surveys

11 slides to run live, two surveys to close the loop

Pink slides are interactive. Both surveys are anonymous; pink questions are written for this course.

Title + agenda (notesDisclaimer - template, not clinical or legal advice, sign-off required; all cases are fictional; check your local classification and query policy {{QUERY_POLICY}})
Word cloudOne word for the hardest record you've had to code from this month.
ScalesScales (chart-quality rating): show three fictional record extracts and rate each for "codable as written" 1-5 (educator reveals which needed a query) [MED-26-V05]
Pick answerWhere is the full code, including laterality and 7th character, chosen?" - Tabular List ✔ · Alphabetic Index · Either [MED-26-V10]
Pick answerAmira: pneumonia found after study; COPD needed extra nebulisers. Principal diagnosis?" - Pneumonia ✔ · Breathlessness · COPD [MED-26-V13]
CategoriseUS inpatient / US outpatient / England" - drag each uncertain-diagnosis rule to its setting [MED-26-V20] [MED-26-V21] [MED-26-V22]
True or falseA fever after surgery can be coded as a complication without a documented link." - False ✔ [MED-26-V18] [MED-26-V19]
Open-endedRewrite this leading query so it's compliant: 'Please document sepsis so the case groups correctly.'" [MED-26-V24]
Pick answerWhich must never appear in a query?" - Impact on payment or quality measures ✔ · Clinical indicators · An 'other' option [MED-26-V24]
Q&AAsk the trainer anything
ClosingClosing - {{SURVEY_URL}}, {{COURSE_URL}}, {{EDUCATOR_CONTACT}}
Post-course feedback: 11 questions, about 2 min
  1. Overall rating 5 stars
  2. Relevant, realistic, right length, helpful activities agree/disagree grid
  3. What was most useful? multi-select
  4. Confidence before this course, and now 1-5 scale
  5. How confident are you applying the right uncertain-diagnosis rule for your setting? 1-5 scale
  6. How confident are you writing a non-leading query? 1-5 scale
  7. Since the course, which have you done? multiple choice
  8. Clinical teams in my organisation respond helpfully to coding queries. 1-5 scale
  9. One thing we should change or add open text
  10. Would you recommend this course? NPS
30-day check-in
  1. Have you used what you learned since the course? multiple choice
  2. How confident are you today? Compare with day 1 1-5 scale
  3. Do you know where to find the official coding guidelines or national coding standards, and the local query policy? yes / no / not sure
  4. A moment where the training helped, or where you weren't sure open text
  5. Which topics should the next refresher focus on? ranking

Results show whether people use the training on the job, not just whether they finished it.

Make it yours

14 fields to fill in, and you're ready

Everything else is done. These are the details only your organisation knows; each one is highlighted inside the course.

  • Classification and version your organisation must use{{LOCAL_CLASSIFICATION}}
  • The national or local coding standards and uncertain-diagnosis rule that apply{{LOCAL_CODING_STANDARDS}}
  • Local clinical documentation standard{{DOCUMENTATION_STANDARD}}
  • Electronic record system and template tips{{RECORD_SYSTEM}}
  • Local query policy, templates and escalation route{{QUERY_POLICY}}
  • Retention and access rules for health records{{RECORDS_RETENTION_SCHEDULE}}
Show all 14 fields
  • Who runs coding audit and how findings are shared{{CODING_AUDIT_LEAD}}
  • Top errors from your recent audits{{LOCAL_AUDIT_FINDINGS}}
  • Your fraud and billing-compliance course{{BILLING_COMPLIANCE_COURSE}}
  • LMS or record system{{LMS_OR_RECORD_SYSTEM}}
  • Survey URL{{SURVEY_URL}}
  • Live session URL{{LIVE_SESSION_URL}}
  • Course URL{{COURSE_URL}}
  • Educator contact{{EDUCATOR_CONTACT}}

FAQ

Common questions

Can I run clinical documentation and coding standards training online?

Yes. The course is self-paced and online, and the live deck lets you add a live session in the room or online.

How often is this training needed?

At induction, with a refresher set by organisation policy, for example when classification versions change.

Who needs this training?

Clinical coders, medical records and health information staff, clinical documentation specialists, and clinicians who write in the record.

What records should I keep?

Record completion in your own LMS or record system, so you can show who finished the course and when.

Can I edit the content?

Yes, everything. Change the wording, swap scenarios for ones from your workplace, add your logo, or remove parts that don't apply.

Related templates

Often taught together

All Professional practice templates →
Global

Clinical reasoning and structured case presentation

Junior doctors · Professional practice

45 min
Global

Valid consent, breaking bad news and just culture

All clinicians · Professional practice

45 min
Global

Safe use of AI and digital tools in clinical practice

Clinicians · Professional practice

40 min
Global

Medical terminology and vital signs for New healthcare staff

New healthcare assistants and support workers · Professional practice

40 min
Last reviewed: 21 October 2026Templates are a starting point, not legal advice.

Ready to run it?

Open the live deck to see how the session runs alongside the course and both surveys.

See the live deck