1
Review the Complete Record
Identify the encounter purpose, documented conditions, services, findings, and relevant supporting details.
Audit-Ready Resource Center
Documentation Decision Trees
Visual frameworks for evaluating documentation completeness, specificity, linkage, consistency, and coding support.
The Five-Step Documentation Review
Use a consistent sequence to review the record, identify documentation gaps, and document a defensible conclusion.
2
Define the Documentation Question
Determine whether the issue involves completeness, specificity, linkage, consistency, time, or clinical support.
3
Follow the Official Guidance
Apply the appropriate official coding guidelines, payer policy, or organizational standard before reaching a conclusion.
4
Determine Documentation Support
Decide whether the record is supported, incomplete, conflicting, unclear, or requires clarification.
5
Document the Next Action
Record the finding, supporting evidence, impact, and whether correction, education, query, or escalation is appropriate.
Core Documentation Decision Pathways
Each pathway starts with a focused question and follows the documented evidence.
Completeness
Decision question: Are all required elements present for the reported diagnosis or service?
YES: Continue to specificity, linkage, and consistency review.
NO: Identify the missing element and determine whether clarification or education is needed.
NO: Identify the missing element and determine whether clarification or education is needed.
Specificity
Decision question: Does the record include the detail needed for the most specific supported code?
YES: Assign or validate the supported level of specificity.
NO: Use a permitted less-specific code or query when additional detail is required.
NO: Use a permitted less-specific code or query when additional detail is required.
Linkage
Decision question: Does the record clearly connect the condition, manifestation, complication, or treatment relationship?
YES: Apply the documented relationship and official guidance.
NO: Do not assume linkage; seek clarification when the relationship is required.
NO: Do not assume linkage; seek clarification when the relationship is required.
Consistency
Decision question: Are the history, assessment, plan, orders, and results internally consistent?
YES: Proceed with the supported conclusion.
NO: Resolve or escalate material conflicts before final coding or audit disposition.
NO: Resolve or escalate material conflicts before final coding or audit disposition.
Time Support
Decision question: Does the record contain the time detail required for the reported service?
YES: Validate the time-based service using the applicable rule.
NO: Do not infer time; identify the documentation gap or query when permitted.
NO: Do not infer time; identify the documentation gap or query when permitted.
Clinical Support
Decision question: Does the documentation support the reported condition, service, risk, or level of care?
YES: Document the supported conclusion and rationale.
NO: Identify the unsupported element and determine the appropriate corrective action.
NO: Identify the unsupported element and determine the appropriate corrective action.
Documentation Review Safeguards
Use these controls to keep documentation findings objective, consistent, and defensible.
Use the Complete Medical Record
Do not make a final decision from one note section, copied-forward statement, or isolated data element.
Follow the Official Guidance
Apply the appropriate official coding guidelines, payer policy, or organizational standard before reaching a conclusion.
Do Not Infer Missing Facts
Document only what the record establishes; seek clarification when required information is absent or ambiguous.
Separate Documentation From Intent
A documentation gap does not automatically establish improper intent, fraud, or abuse.
Describe the Finding Objectively
State what is present, missing, conflicting, or unsupported without overstating the evidence.
Preserve the Audit Trail
Retain the reviewed evidence, applicable guidance, rationale, disposition, and follow-up action.
Three Questions Before Finalizing
QUESTION 1Does the medical record support my decision?
QUESTION 2Did I follow the applicable official guidelines, payer policy, or organizational standard?
QUESTION 3Could another coder or auditor reproduce the same conclusion from the same record?
Think Like an Auditor. Code with Intent. Defend with Confidence.