My Favorite Documentation Fail (and What It Taught Me)
Article Reference Code: NAMAS.03.13.2026
Written by: Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CDEO, CPB, CFPC, CRC, CPEDC, CPCO, CMRS, CMCS, CEMA
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. Because sometimes the note tells one story, and the provider tells another. One memorable audit involved what appeared to be a medical necessity issue. The visit was billed at a high level of service. The patient had multiple chronic conditions, but the plan was simply a list of diagnoses followed by the familiar phrase “continue medications.” From an auditor’s perspective, the documentation simply did not support the code.
During the post-audit education discussion, however, the provider filled in a critical part of the story. While that patient was in the exam room, another patient in the office coded. The provider had to rush out to assist. In the chaos that followed, the documentation for the earlier visit was not completed. The care happened. The documentation did not. My takeaway from this was a reminder that auditors see the note, not what was happening in the visit. Sometimes our most important first step is simply asking what happened.
Another audit appeared to be a big copy-and-paste failure. One note was quite detailed and looked great, except the exam findings did not match the presenting problem. After further digging, it was clear the exam had been pulled forward from a previous visit. When I pointed this out to the provider, his explanation revealed a problem he had been struggling with for some time. The EMR automatically pulled the exam from the prior visit into each visit note, and he had missed updating the exam findings for that encounter. Because we were able to identify the root of this problem, the organization was able to turn off the function causing potential conflicts in the notes. This lesson was a reminder that not every documentation problem begins with the provider. Sometimes the technology designed to help is actually contributing to the problem.
I really dislike seeing providers billing split/shared visits because often they don’t understand the rules. I had this in the back of my mind while auditing a hospital note. The visit was billed under a physician, but most of the documentation reflected the work of the advanced practice provider. The physician’s entry consisted of a short statement agreeing with the plan, so at first glance it appeared the visit had been billed incorrectly. During the follow-up discussion, however, the physician explained that she had seen the patient, but her notes were in a different section of the EMR that had not been included in the materials provided for the audit. While the documentation still needed to be aligned more clearly, it was a reminder that we review only the documentation provided, but the full story may be spread across different areas of the chart.
Time-based billing can also be a documentation struggle. Once, a provider documented spending forty minutes face-to-face with the patient and billed the level of service accordingly. At first glance the note seemed appropriate, but it included activities that are often not performed during the visit itself. When we discussed the finding, the provider explained that a good portion of the time had been spent earlier that day reviewing outside records and coordinating care. The documentation simply did not clarify the timing. It was a simple wording issue, but it reminded me how easily the author of the note can interpret their documentation very differently than we do when we read the note with an auditor’s eye.
If you audit primary care, I know you have seen this: a slew of diagnoses in the assessment, but the plan only addresses one of them. The rest simply sit there while we wonder why the provider bothered to include them in the note. When I ask about this, the provider’s explanation is usually that the conditions were reviewed and stable—but that information never made it into the documentation.
All of these examples remind us that just because something isn’t documented doesn’t mean it wasn’t done. Our job is to identify areas of concern and help documentation better reflect the care that actually occurred. But the audit process itself also matters. We are more than auditors—we are also educators who help translate between clinical care and compliance expectations.
As partners with our providers, our goal doesn’t stop at identifying documentation failures. We help providers clearly tell the story of each patient visit. The reality is that most providers are not trying to fail at documentation; they are trying to care for patients while a million other tasks compete for their attention. While this does not change the need for good documentation, understanding this may help us give our providers a little grace by starting with one simple question: “Can you help me understand what happened during this visit?”
Because although the note is the record we audit, it doesn’t always tell the whole story. The most important lesson I have learned from auditing a lot of documentation fails is that good auditing requires much more than reading a note. It requires listening to the people who created it.
In memory of Heather Bollman, my “you’ll never believe what I saw in this note today?!” friend.
Contact Pam on LinkedIn by Clicking her Name Below:
Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CDEO, CPB, CFPC, CRC, CPEDC, CPCO, CMRS, CMCS, CEMA
Pam Vanderbilt is a passionate educator, consultant, and advocate for excellence in healthcare and life. As President of Knowledge Tree Billing, Inc., she leads a revenue cycle management team while serving as an education and consulting resource for providers, coders, auditors, billers, and practice managers, with a strong focus on compliance in the business side of healthcare.
With expertise in revenue cycle management and a commitment to patient-centered care, Pam helps healthcare professionals understand how accurate documentation supports compliance, operational efficiency, and financial health. Through webinars, conference presentations, articles, and consulting, she has educated thousands of professionals on navigating complex healthcare regulations and translating them into practical, real-world improvements.
NAMAS BLOG Disclaimer:
The NAMAS Blog features content written by both NAMAS staff and guest contributors. Guest contributors may present opinions or perspectives that differ from those officially instructed or encouraged by NAMAS. We believe in providing space for a range of informed viewpoints to foster dialogue, reflection, and deeper understanding within the auditing and compliance community.
Some contributors may use artificial intelligence (AI) tools in the development of their content. The decision to incorporate AI is left to the discretion of the author and does not reflect an endorsement or directive from NAMAS.
If you have questions, comments, or concerns about a specific blog post, we encourage you to contact the individual author directly. Their name and contact information are provided at the end of each post.
