📋 Audit Checklist
🎯 Purpose
A quick audit reference to ensure documentation supports coding accuracy and MDM level.
1️⃣ Problems Addressed
- Each problem clearly documented
- Severity or status noted
- Chronic conditions linked to visit
- Exacerbations described
2️⃣ Data Reviewed
- Labs/imaging reviewed AND documented
- Tests ordered linked to problems
- External notes reviewed
- Independent historian documented (if used)
- Independent interpretation documented
- External discussion documented
3️⃣ Risk
- Prescription drug management documented
- Escalation of care noted
- Surgery decisions documented
- Risk factors clearly stated
- Shared decision-making captured
🧠 General Documentation
- Clear HPI
- Relevant ROS
- Exam supports problems
- Assessment & Plan detailed
- Medical necessity supported