Clinician-Created Documentation Auditing Skill Builder

Published: January 2025

The Clinician-Created Documentation Auditing Skill Builder is comprised of the following:

• Complete medical reports including ED, H&Ps, Consultations, and Discharge Summaries for the auditor to audit/analyze.
• Excerpts from specialty medical reports including Cardiology, Dermatology, Emergency Medicine, Endocrine, ENT, GI, Hematology/Immunology/Oncology, Infectious Disease, Laboratory, Medications Nephrology, OB/GYN, Ophthalmology, Orthopedics, Pathology, Pediatrics, Psychiatry, Pulmonology, and Urology for the auditor to audit/analyze.
• Knowledge-validating interactive exercises including Multiple Choice, True or False, Critical or Noncritical, etc.
• Answer keys.

Each section offers a unique opportunity for the auditor to learn or practice the skills required to successfully identify critical errors contained within clinician-created documentation. Actual reports and examples have been used to try to emulate the auditing environment as much as possible. Although some editing has been done, most reports reflect the actual EHR-generated documentation (content and formatting). Using their medical knowledge and experience, as well as critical thinking skills, the auditor may work through each section at their own pace and in no particular order.

After you purchase the eBook, you will have access to the book under your account download button.  The reports can be printed, or you may use the highlight feature to mark errors.  The interactive exercises are assessable by clicking the certificate button and then clicking on each exercise link. 

CEC: 10 Technology & Tools (TT)

Regular List Price: $90.00
Regular Eligible Member Price: $65.00