Documentation: Look to Peer Audits to Improve E/M Documentation

Article Overview

This article covers a practical approach to improving evaluation and management documentation through peer audit. It is aimed at clinicians, coders, and audit staff who want to evaluate whether records support clinical decision-making, improve the uniqueness and completeness of encounter notes, and connect documentation review with follow-up coding audit processes. The discussion stays focused on general documentation quality, audit steps, and internal review methods rather than coding-specific instructions.