There is an interesting moment that happens in the course of conduction an audit. You open the note. You start reading. You think, "Okay, we’re off to a strong start." But then, something shifts. The further you read, the more it starts to feel... like too much. The documentation is packed to the brim. Every lab result ever ordered is present. Every prior diagnosis is listed. There is a paragraph on family history when the service is based on medical decision making. And suddenly, it hits you. This documentation is trying too hard.



Let me be clear. Most providers mean well. They want to document appropriately. But sometimes their efforts to be thorough cross the line into over-documentation. That can create confusion, misrepresent the actual service provided, and even raise compliance concerns.

Let’s break down three common examples of when documentation tries too hard, and how both the auditor and the educator should handle it.

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