UDS Table 6B Pre-Submission Data Validation Checklist
Validate UDS Table 6B numerators and denominators against source records before submission, so reporting errors are caught early and corrected with a clear audit trail.
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Overview
The UDS Table 6B Pre-Submission Data Validation Checklist is a pre-filing inspection template for confirming that reported clinical quality measure numerators and denominators match source records before annual submission. It is built to help reviewers verify the reporting year, measurement period, source records, population logic, exclusions, numerator evidence, reconciliation, and final approval in one controlled walk-through.
Use this template when your team has already built the UDS extract and needs a structured review before filing. It is especially useful when multiple people touch the data, when the measure logic is maintained outside the EHR, or when prior submissions have been corrected after internal review. The checklist helps document what was checked, what was found, and what was approved, which is useful for audit readiness and internal accountability.
Do not use this as a substitute for the official UDS instructions or the underlying measure specifications. It is not a clinical policy, and it should not be used to define measure logic from scratch. If your organization has not yet agreed on the denominator rules, exclusion handling, or numerator timing requirements, resolve those upstream first. The template works best when the reporting logic is already defined and the goal is to validate that the final counts are accurate, traceable, and ready for submission.
Standards & compliance context
- This checklist supports internal control practices commonly expected in UDS reporting workflows and helps demonstrate traceability from source records to submitted counts.
- The validation steps align with quality management principles used in ISO 9001-style document control and reconciliation processes.
- Where clinical quality measures depend on documented care, the template helps verify that numerator evidence is consistent with the applicable reporting instructions and organizational policy.
- If your organization uses external audit or grant oversight processes, the checklist provides a documented review trail for deficiencies, corrective actions, and final approval.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Inspection Details
This section establishes the reporting context, reviewer authority, and source set so the validation is tied to the correct submission cycle.
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Reporting year and measurement period confirmed
Enter the UDS reporting year and the exact measurement period being validated.
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Reviewer identified and authorized
Enter the name and role of the reviewer performing the validation.
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Source records included in review are documented
Select all source record types used to validate the measures.
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Validation method documented
Select the method used to validate numerator and denominator counts.
Measure Population and Denominator Validation
This section verifies that the reported population matches the measure rules before any numerator review begins.
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Age and eligibility criteria match UDS Table 6B specifications
Verify that age, visit, and enrollment criteria align with the measure definition.
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Denominator count reconciles to source population
Enter the validated denominator count and compare it to the reported value.
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Exclusions and exclusions rationale documented
Confirm that exclusions were applied consistently and supported by documentation.
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Duplicate patients removed appropriately
Verify that patients were counted once per measure according to reporting rules.
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Denominator logic matches report query or extraction
Confirm that the denominator logic used in the report matches the validated query logic or extraction criteria.
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Population stratification documented where applicable
Confirm that any required stratification or subgroup logic is documented and traceable.
Numerator Validation
This section confirms that each counted case is supported by clinical evidence and meets the measure timing and threshold requirements.
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Numerator count reconciles to source records
Enter the validated numerator count and compare it to the reported value.
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Clinical evidence supports numerator inclusion
Verify that source documentation supports each patient included in the numerator.
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Measure-specific timing requirements met
Confirm that the clinical event, test, or intervention occurred within the required time window.
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Result values or clinical thresholds verified
Confirm that the documented result meets the measure threshold, if applicable.
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Missing or ambiguous documentation resolved
Verify that any unclear documentation was resolved using approved source records or follow-up review.
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Outliers and exceptions reviewed
Confirm that unusual cases, overrides, and exceptions were reviewed and documented.
Data Integrity and Reconciliation
This section checks that the extracted report, source records, and final counts all agree and that anomalies are explained.
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Reported counts match validated counts
Confirm that the final report values match the validated numerator and denominator counts.
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Data extraction logic reviewed and approved
Verify that the extraction logic, filters, and code sets were reviewed before submission.
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Missing data rate assessed
Enter the estimated missing data rate for the validated measures.
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Data anomalies documented and investigated
Confirm that discrepancies, outliers, and unexpected trends were investigated and documented.
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Version control or final file name recorded
Record the final validated file name, report version, or submission package identifier.
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Independent reconciliation completed
Confirm that a second reviewer or independent reconciliation was completed where required by internal policy.
Submission Readiness and Sign-Off
This section captures whether all critical deficiencies are resolved and whether the file is approved for filing.
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All critical deficiencies resolved
Confirm that no unresolved critical items remain before submission.
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Corrective actions assigned for open non-conformances
Verify that each open issue has an owner, due date, and documented corrective action.
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Submission approved for UDS filing
Indicate whether the validated Table 6B data is approved for submission.
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Inspector signature
Signature of the reviewer completing the validation.
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Approval date and time
Record the date and time the validation was completed and approved.
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Final comments
Summarize any remaining issues, assumptions, or follow-up items.
How to use this template
- 1. Enter the reporting year, measurement period, reviewer name, and source record set so the checklist is tied to a specific submission cycle.
- 2. Confirm the denominator logic against the UDS Table 6B specification and compare the extracted population to the source patient list.
- 3. Review numerator support record by record, checking timing, thresholds, and clinical documentation for each included case.
- 4. Reconcile reported counts to validated counts, document any anomalies or missing data, and assign corrective actions for each open deficiency.
- 5. Complete independent reconciliation, record the final file name or version, and obtain approval, signature, and timestamp before filing.
Best practices
- Use the official measure definitions as the reference point before you validate any extracted count.
- Trace every denominator inclusion back to a source record or documented rule, especially when exclusions are involved.
- Review duplicate patients and merged charts early, because identity issues often distort both numerator and denominator counts.
- Flag any measure with ambiguous documentation for clinical review instead of guessing at inclusion.
- Document the exact source files, report version, and extraction date so the validation can be reproduced later.
- Treat missing data, outliers, and unexpected threshold values as defects until they are explained and resolved.
- Require an independent reviewer to reconcile the final counts before sign-off, not after submission.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What does this UDS Table 6B pre-submission checklist cover?
This template covers the full pre-filing validation of UDS Table 6B clinical quality measure data. It walks through reporting year confirmation, denominator logic, numerator support, reconciliation to source records, and final sign-off. It is designed to catch non-conformances before the annual submission is locked.
Who should use this checklist?
It is typically used by quality managers, clinical informatics staff, data analysts, and a reviewer with authority to approve the final file. A clinician reviewer is often needed for measure interpretation when documentation is ambiguous or exceptions need clinical judgment. The person completing the checklist should be able to trace counts back to source records and the extraction logic.
How often should this checklist be run?
Run it before each annual UDS submission and again whenever the source extract, measure logic, or reporting file changes. Many teams also use it during internal dry runs so they can resolve deficiencies before the final reporting window. If your organization updates workflows mid-year, a mid-cycle validation can reduce last-minute reconciliation issues.
Does this template replace the UDS reporting instructions?
No. This checklist is a control tool that helps you verify your data against the applicable UDS Table 6B specifications and your source records. It does not replace the official reporting instructions, measure definitions, or internal governance review.
What are the most common mistakes this checklist helps catch?
Common issues include incorrect age or eligibility logic, duplicate patients left in the denominator, numerator evidence that does not meet the timing requirement, and counts that do not reconcile to the final report. It also helps surface missing documentation, unresolved anomalies, and extraction logic that was not independently reviewed. Those are the kinds of defects that often create avoidable submission corrections.
Can this checklist be customized for our EHR or data warehouse?
Yes. You can adapt the source record fields, extraction notes, and reconciliation steps to match your EHR, registry, or reporting warehouse. The structure should stay focused on what the reviewer must verify: population logic, numerator support, data integrity, and approval.
How does this template support audit readiness?
It creates a documented trail showing who reviewed the data, what sources were checked, how counts were reconciled, and what corrections were made. That makes it easier to explain the final submission if questions arise later. It also helps demonstrate a repeatable internal control process rather than an ad hoc review.
What should be done if the validated counts do not match the report?
Treat the mismatch as a non-conformance and pause submission approval until the cause is identified. Review the extraction logic, duplicate handling, exclusions, and source documentation, then update the report or the underlying data as appropriate. Record the corrective action and independent reconciliation before sign-off.
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