The Audit Starts Before the Note
Article Reference Code: NAMAS.01.16.2026
Written by: Shannon O. DeConda, CPC, CPMA, CEMA, CEMC, CPA-EDU
When we think about an audit, we often picture a finalized encounter. The note is signed, dated, and ready for review. But the reality is, the audit does not begin with the note. It begins much earlier.
Technically, the audit begins at the moment the encounter is initiated, not when the documentation is completed.
Too often, our focus is entirely on the medical record, as if it exists on its own. However, the documentation is a result. It is the product of how the provider thinks, how they approach the patient’s encounter, how they gather and interpret information, and how they understand documentation requirements. If we wait until the note is finalized to begin evaluating it, we are already behind.
We should be encouraging auditors and educators to shift this perspective. Instead of reacting to documentation that is already created, we must observe and influence the process that leads to the final product… the documentation.
A strong audit process identifies areas for improvement long before the note is signed.
So, this should make your wheels turn and you should be asking, “Shannon, where does the audit actually begin?”
Let’s touch on just a few:
⇒ Template Structure and Use: I feel like at this point in the article, many people start glazing over, because since the adoption of EMRs, this has been a constant conversation. We’ve said it in audits, in education sessions, and in post-review meetings, yet the issue persists. Auditors and coders are still frequently excluded from the creation, establishment, and ongoing updates of EMR templates, even though those templates directly impact documentation, coding, and compliance.
Not involving a coding or auditing professional in template development is a lot like deciding to pack your own parachute for a skydive because you’re confident in how well you fold towels. You understand the basic concept. You know things need to be neat and orderly. And to the untrained eye, the end result might even look acceptable.
But parachutes are not towels, and EMR templates are not neutral tools.
The risk is not in whether the template looks good. The risk is in whether it functions correctly when it matters. A poorly designed template can quietly introduce overdocumentation, omit required elements, or create inconsistencies that surface later in audits and denials. At that point, the damage is already done.
The cost of involving an auditor or coder in template design is minimal. The cost of fixing systemic documentation issues after the fact is not. Templates should be built by professionals who understand how documentation is evaluated, how codes are supported, and how compliance risk actually presents in the real world.
This is not about perfection. It is about recognizing that some things are worth doing with the right expertise from the start.
⇒ Documentation Habits: There are patterns and problems that surface over and over again in audits. We see them in the reports. We call them out. But often, because the issue doesn’t drastically affect the final score, or because the provider is a high-volume producer, the decision is made to let it slide.
But at some point, we must ask: when does a pattern stop being something we tolerate and start being something we correct?
When does habitual overdocumentation start impacting downstream HCC capture and ACO performance? When do we stop overlooking late signatures or loosely applied attestation requirements for scribes and medical students?
These are not just compliance footnotes. They are risks. And by the time they surface in an audit, the opportunity to proactively address them may have already passed.
Ignoring documentation habits because they are inconvenient to confront is not a long-term strategy. These trends need to be addressed before they compromise audit outcomes, financial integrity, or the organization’s reputation.
⇒ Education Gaps: I remain astonished by the number of organizations that openly acknowledge their providers have never received formal education on the current E/M guidelines. We hear it regularly. The guidelines changed, and yet there was no structured training, no in service, no reset.
If tax law changed, their CPAs would be waist deep in the new regulations immediately. But when it comes to E M guidelines, which carry significant financial risk and expose organizations to penalties and fines that can multiply the value of a claim many times over, providers are often left to figure it out as they go. They continue to document, select a code, and submit claims without ever being given a clear understanding of what is required.
When organizations come to us in this position, our response is direct. We will not audit your providers until they are given a fighting chance to be right. Auditing first, without education, sets everyone up for failure. We already know what those results will look like, and they will not be productive.
Education must come before evaluation. Providers should not learn E/M requirements through audit findings. They should learn them through structured, intentional training. This is not an audit results session. This is a straightforward E/M education session. Here is what the guidelines say. Here is how documentation is evaluated. Here is how codes are supported.
We believe all coders and auditors should complete formal E/M guideline education at least annually. We also believe all providers should attend a mandatory E/M in service no less than once a year. That is how you build accuracy, confidence, and compliance. That is how you set providers up for success.
Auditing is not just about identifying what is wrong. It is about understanding the “why” behind the documentation and guiding providers toward improvement.
A meaningful audit does not simply point out a level that was not supported. It asks, “What part of the process led to this outcome?” and “How can we adjust the approach so that the documentation supports the appropriate level in the future?”
When we see ourselves not just as reviewers but as participants in the documentation process, our impact grows. We move from oversight to leadership.
A compliant note is not created by chance. It is the result of preparation, education, and aligned processes. Compliance is not something we hope to find at the end of an encounter. It is something we build intentionally from the start.
As professionals committed to auditing and documentation excellence, we must:
- Educate before we evaluate
- Support before we score
- Improve before we identify gaps
The audit starts before the note, and so should our efforts.
Shannon O. DeConda, President & Founder of NAMAS, a division of DoctorsManagement & VP of Regulatory Compliance at DoctorsManagement
With over 25 years of experience in coding, auditing, and compliance, she’s been instrumental in shaping how healthcare professionals understand documentation, regulatory standards, and audit accuracy. Shannon is the original developer of the CPMA credential and continues to lead national education efforts through NAMAS, where she specializes in turning complex compliance topics into practical, easy-to-apply strategies.
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