A growing concern among auditors, coders, and compliance professionals is the increasing reliance on template driven documentation. While electronic health records have improved efficiency, copied, carried-forward, and pre-populated information can create significant compliance risks when it does not accurately reflect the patient’s current encounter.

Auditors frequently identify contradictory statements, outdated histories, normal findings that conflict with the assessment and plan, and documentation that appears disconnected from the services actually provided. Simply completing documentation fields does not create credible documentation.

On this episode of the CodeCast Podcast, Terry discusses why E/M documentation is not a checklist, the compliance risks associated with template generated notes, and practical strategies to ensure your documentation accurately tells the patient’s story and supports the care delivered.

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