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Common Findings and How to Avoid Them

Module 12: Documentation, Notes, and Billing Integrity · Lesson 2 of 3

Auditors see the same six problems everywhere.

Late notes, cloned notes, time not supported by content, services outside the plan, missing signatures, and activity-only descriptions. Every one is preventable with a routine.

Document in the field between visits. A note written three days later is both less accurate and less defensible.

Key takeaways

Same-day documentation is a non-negotiable habit
Content must justify the time billed