The One Note That Broke Me: Auditing Horror Stories
Article Reference Code: NAMAS.07.31.2026
Written by: Emily Schmidt, JM, MS, RHIA, CCS, CPC, CPCO, CPC-P, CDEO, CPB, CPMA, CPMS, CRC, CVBA, CPC-I
It was a typical day of auditing. I had a stack of paper charts sitting on the desk in front of me, a cup of tea nearby, and my code books at the ready for whatever I might uncover in those medical records. It was early in my auditing career, but nothing excited me more than conducting full chart reviews and digging through records to validate code submissions.
I moved through my first chart with relative ease. The second chart was more of the same—straightforward, with no errors that I could see. Then I opened the third chart.
I flipped open the file folder and started reading the first progress note. It was dated two weeks prior, and the first sentence in the HPI read, “Patient coughed three days ago and strained her back.” As expected, amid documentation of her myriad chronic conditions being managed that day, I identified problem-specific documentation related to the strained muscles in her back. The HPI described the timing and severity of the problem, the ROS reflected the patient’s pain, and the physical exam noted tenderness in the lower back on palpation. The assessment and plan were also clear. Everything checked out, and we were good to go.
I moved on to the next progress note in the chart. This one was dated six weeks before the date of service I had just reviewed. As I started reading, I thought perhaps an error had occurred in the medical records department because the first sentence of the note said, “Patient coughed three days ago and strained her back.” I double-checked the dates, and everything appeared to be correct—except for the fact that the first line was identical to the note I had just audited.
I flipped to the next progress note in the chart, and sure enough, the first line was once again the same.
At that point, a feeling of dread started to creep in. I continued flipping through the chart to see where this sentence first originated. By the time I finished, I had identified nine consecutive office notes over an eighteen-month period that contained the exact same sentence: “Patient coughed three days ago and strained her back.”
It was clear to me that there were only two possible explanations. Either the provider was carrying information forward from visit to visit through copy-and-paste functionality, or the patient was extraordinarily consistent in coughing and straining her back exactly three days before every appointment. Given the unlikely nature of the latter, I knew I needed to have a conversation with the provider.
One of the most important components of a documentation and coding audit isn’t the audit itself. While it is essential to ensure the audit is conducted accurately and in accordance with applicable guidelines and regulations, it is equally important to act upon the findings. Without post-audit education and discussion with those whose work was reviewed, there is a strong likelihood that errors will continue to be repeated.
The true value of an audit lies in its results. Results are actionable. They provide opportunities to improve documentation practices, strengthen compliance, and reduce future risk.
In the case of the patient with the seemingly chronic strained back, the provider vehemently denied any carry-forward or copy-and-paste activity when I first met with him. Fortunately, I came prepared. I had copies of the notes, along with relevant coding guidelines and CMS guidance.
I approached the conversation carefully. Rather than making accusations, I simply showed him what I had found and asked him to help me understand the rationale behind the documentation. When faced with visual evidence of nine identical statements spanning eighteen months, he acknowledged it was “possible” that he had carried forward HPI information without updating it at each visit.
Sometimes audits lead to fascinating discoveries. Sometimes providers are resistant to feedback and bristle at the thought of being educated by an auditor. However, when done correctly, audits create unique opportunities to understand a provider’s thought process, identify the root cause of documentation issues, and help providers develop more effective and compliant documentation habits.
And me? At the time, that chart felt like it broke me.
I was still finding my footing as an auditor, and I suddenly found myself needing to have a difficult conversation with a difficult provider. What started as a routine chart review became a crash course in confidence, communication, and professional diplomacy. Nearly fifteen years later, I’m still going strong as an auditor. That experience taught me how to thoroughly document my findings, communicate them clearly and professionally, and develop strategies that help providers avoid similar errors in the future.
Looking back, maybe that note didn’t really break me after all.
Contact Emily LinkedIn by Clicking her Name Below:
Emily Schmidt, JM, MS, RHIA, CCS, CPC, CPCO, CPC-P, CDEO, CPB, CPMA, CPMS, CRC, CVBA, CPC-I
Emily Schmidt, JM, MS, RHIA, CCS, CPC, CPCO, CPC-P, CDEO, CPB, CPMA, CPMS, CRC, CVBA, CPC-I, is a healthcare coding and compliance professional with a passion for education, physician documentation, and empowering coding professionals to succeed. Throughout her career, she has worked across physician coding, auditing, compliance, and documentation improvement, helping organizations strengthen coding accuracy while navigating an ever-changing regulatory landscape. Emily is known for her practical, real-world approach to coding education, making complex concepts accessible and applicable for both new and experienced professionals.
As an educator, Emily is committed to fostering confidence and critical thinking in coders and auditors. She enjoys sharing her knowledge through training, mentoring, and professional development opportunities, believing that education is one of the most powerful tools for improving compliance and supporting quality patient care. Her dedication to lifelong learning and advancing the profession continues to inspire those she teaches and collaborates with.
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.
