Clinical Audit IQ · Free documentation check
Would this clinical note pass a documentation review?
Pick a type of documentation, read a fictional note, make your call, then see what Clinical Audit IQ finds: medical necessity gaps, time that doesn't support the code, treatment-plan mismatches and missing elements, each explained, with the rule it comes from where one applies.
Every note here is fictional and written with deliberate gaps. Nothing to upload, no sign-up to try it. Results show documentation readiness only; they don't predict payment or a payer's decision.
Free guide
Behavioral Health Documentation Audit Readiness Checklist
What reviewers look for in progress notes, treatment plans and assessments, and how to check your own records first.
- The core elements every behavioral health note needs
- Time-based code checks and common mismatches
- Treatment plan currency and alignment checks
- How to correct records properly (and what can't be corrected)
- A fictional before-and-after note
About this check
- The findings come from the same rule engine that runs in Clinical Audit IQ, applied to these fixed fictional records.
- Which rules apply depends on the code, the payer and the state. These samples use Kentucky Medicaid or Medicare; other states' Medicaid rules in the library are listed on the Clinical Audit IQ page. Codes without verified code-specific rules are checked against general documentation standards, and the review says so.
- Clinical Audit IQ is decision support for documentation quality. It doesn't verify that a service happened, add anything that wasn't documented, or guarantee an audit or payment outcome.