Free worksheet · No email required
Coding audit evidence checklist
Give the next reviewer enough context to find the source, understand the exception and see who made the decision. Use this worksheet for one finding in an RCM coding or documentation review queue.
Eight checks before handing off a finding
- 01
Identify the source
Record the document ID, version and review scope so another reviewer can open the same material.
- 02
Pinpoint the passage
Include the page, section and exact excerpt. A filename alone leaves the next reviewer searching again.
- 03
Separate evidence from interpretation
State what the source says, then describe the proposed finding. Label evidence as supporting, conflicting, missing or not assessed.
- 04
Make gaps explicit
For missing evidence, record where you looked and the limits of the packet. Do not invent a quote or treat absence in a sample as proof of absence everywhere.
- 05
Record the review basis
Name the applicable review criterion and its version. If the criterion is unresolved, flag it for the qualified reviewer instead of asserting a coding conclusion.
- 06
Keep a human decision trail
Record the responsible reviewer, decision, reason and timestamp. Distinguish a proposed finding from an approved result.
- 07
Assign the next action
For unresolved or conflicting findings, name the owner and the next step. Keep clarification separate from approval.
- 08
Preserve the record downstream
Check that exports retain source coordinates, uncertainty and reviewer actions. Record evidence-search time separately from total handling time when comparing workflows.
Copy the blank finding record
One record per finding. Copy this into your approved workspace to fill it in. This page does not accept patient information.
Entirely synthetic · No patient data
Example: an incomplete signature field
This fictional documentation check illustrates the record format. It does not establish a coding, billing or medical-necessity decision.
- Source
- SYN-DOC-001 · version 1 · page 2 · Sign-off section
- Exact excerpt
- “Reviewer signature: [blank]”
- Proposed finding
- The signature field is empty in the supplied version.
- Evidence state and scope
- Missing signature in version 1. Only pages 1–2 were checked; no later version was supplied.
- Review basis
- Fictional internal criterion DEMO-01 v1: the review packet includes a completed sign-off field.
- Human decision
- Demo reviewer A · defer · 2026-09-11 09:00 UTC. Confirm whether a completed version exists before closing the finding.
- Next action
- Demo queue owner: locate the completed version or route for clarification. No claim action is authorized.
See the evidence workflow in action
Start with the synthetic demo. If the worksheet exposes a repeated search bottleneck, request a review of your workflow using process details only.