The short answer
An internal documentation audit checks a sample of charts against payer and state rules before an outside auditor does. Look at each note's required elements, whether time and content support the code billed, whether it ties to a current treatment plan, and whether signatures and dates are complete.
Progress note checklist
- Client identifiers, date of service, and place of service.
- Start and stop times (or total time) for time-based codes, matching the code billed.
- The service type and who provided it, with credentials.
- The focus of the session and the interventions used, not just what the client said.
- The client's response and progress toward a treatment plan goal.
- Risk assessment when indicated, and the plan for next steps.
- Signature, credentials and date, within your required time frame.
Chart-level checklist
- A current assessment that supports the diagnoses.
- A current, signed treatment plan that covers every service billed.
- Consents, releases and required notices on file.
- Authorizations matching the dates, units and codes billed.
- Coordination of care with other providers when appropriate.
How to run an internal audit
- Pick a random sample: for example, 5 to 10 notes per clinician per quarter, and more for new staff or high-risk codes.
- Score each note against the same checklist.
- Note patterns by clinician, service and payer.
- Give specific feedback and training, then re-audit to confirm improvement.
- Keep audit records as part of your compliance program.
Frequently asked questions
How often should a behavioral health practice audit documentation?
Many practices audit a sample every month or quarter, with more frequent reviews for new clinicians or after payer findings.
What do auditors look for in progress notes?
Required elements, time that supports the code billed, medical necessity, a link to the treatment plan, and complete signatures and dates.
Related resources
From JV Clinical Technologies, founded by Jaime Varney, PMHNP-BC. General professional education only, not legal, billing or clinical advice for a specific case. Check current payer, state and professional rules before relying on any requirement described here.