Every medical auditor has experienced it. I don’t know about you, but I can honestly say that I have audited some notes in my day that left me feeling like a teacher with a red pen grading a test… and the note ended up with a big fat “F.” When it came time to do the post-audit education, I was ready to walk into the meeting with guns blazing and “fix” everything the provider was doing wrong. And every time that happened, I ended up having a “Whoa, Nellie” moment. I feel confident most, if not all of you, can relate.

Then the chart starts telling a story—or more accurately, it stops telling the story. The assessment is robust but the plan is non-existent. The documentation doesn’t support the level of service that was billed. We are left thinking, “What am I missing here?” We have all audited notes that looked like documentation disasters. At first glance, they seemed to represent every compliance concern we are trained to look for: no MDM, overutilization of smart tools, time statements that don’t explain anything, or—my favorite—36 diagnoses in the assessment with no documentation of why.

But the most valuable lessons I learned from those charts did not come from the documentation itself. They came from what happened after the audit.

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