Codara's product sits within a framework of professional and regulatory standards specific to clinical coding and the documentation that supports it. This page sets out the clinical, professional, and records-management standards that shape how we design and operate the product, with references to the specific sections that apply.
Clinical coding standards
These are the standards Codara is built against. Our coding models, update cycles, and external review processes are all anchored to them.
- National Clinical Coding Standards — published by NHS England's Terminology and Classifications Delivery Service. Codara's coding models are built explicitly against the current National Clinical Coding Standards for OPCS-4 and ICD-10.
- Coding classifications — Codara tracks every OPCS-4 and ICD-10 release published by NHS England's Terminology and Classifications Delivery Service and updates coding models to reflect the current edition.
- External clinical review — Codara's coding models are externally validated by accredited clinical coding experts. Every change to our models is independently scrutinised and re-validated before release. We also work directly with your hospital coding team to apply local policies and conventions.
Clinical documentation standards
Codara is designed to support clinicians in producing documentation that aligns with the standards published by the relevant Royal Colleges and the GMC. The specific documents and sections that apply are below.
Royal College of Radiologists
- Document: Standards for interpretation and reporting of imaging investigations (PDF) — 3rd edition, October 2025
- How Codara aligns: Codara supports radiologists in producing reports that align with the structured reporting principles in Section 5 (The report).
Royal College of Surgeons
- Document: Good Surgical Practice 2025 (PDF) — published 20 March 2025
- How Codara aligns: Codara's surgical documentation templates capture the data elements required by Section 3.5 (Record your work clearly, accurately and legibly), providing structured prompts that mirror the RCS-mandated content for operative notes.
General Medical Council
- Document: Good Medical Practice 2024 — effective 30 January 2024
- How Codara aligns: Codara captures structured documentation at the point of care, with clear attribution to the authoring clinician and a verifiable timestamp, supporting clinicians in meeting Paragraph 69-71 (Domain 3).
Records management
Codara supports NHS customers in meeting their statutory and professional obligations around clinical records. We do not replace the records management responsibilities held by Trusts and clinicians, but we are designed to operate consistently with them.
NHS England
- Document: Records Management Code of Practice
- How Codara aligns: Records produced by Codara meet the four ISO 15489-1:2016 characteristics set out in Section 3.2 (authentic, reliable, integral, useable), and Codara supports Trust customers in meeting their retention obligations under Appendix II.
Care Quality Commission
- Document: Regulation 17: Good governance
- How Codara aligns: Codara's design supports providers across multiple Regulation 17 obligations. For example, under Regulation 17(2)(a) Codara provides accurate, structured clinical data that enables Trusts to assess, monitor and improve the quality and safety of services, and under Regulation 17(2)(c) Codara produces structured records of care attributable to the authoring clinician.
National Data Guardian
- Document: The Caldicott Principles
- How Codara aligns: Codara supports the eight Caldicott Principles across multiple areas. For example, Principle 3 (use the minimum necessary confidential information) is supported by structured data capture that collects only what is necessary for the coding workflow, and Principle 7 (the duty to share information for individual care) is supported by writing the completed record back to the patient's EPR to ensure continuity of care.
This is a living page and will be updated as new standards are introduced or revised. For specific evidence, conformance mappings, or to discuss how Codara aligns with a standard not listed here, contact contact@codara.co.uk.