For Maryland professionals & organizations

Clinical documentation review

Bring a fresh perspective to documentation.

Documentation questions may arise when an organization is revisiting its processes, preparing for a review, or trying to understand where staff need support. Start by identifying the question a review should answer.

Discuss your project

Purpose. Scope. Partnership.

01 / Define the work

Set boundaries for the review

Discuss the type of documentation, the workflow around it, and what you want assessed. Agree on the materials needed, any sampling approach, and the form of the feedback before sharing records. An initial inquiry should describe the problem at an organizational level without including client-identifying information.

02 / Define the work

Turn observations into defined next steps

Depending on the agreed scope, feedback can inform a discussion about internal guidance, policy changes, or training needs. Clarify who will interpret and implement recommendations, whether follow-up is included, and how the work relates to a broader compliance project. A documentation review does not promise payment, audit clearance, or acceptance by another organization.

Clear expectations before work starts

Arrange an appropriate method for any records exchange after scope and responsibilities are established. Do not attach clinical records to a general inquiry.

Questions about clinical documentation review

A little clarity
before you begin.

Should I send sample client notes in the inquiry?

No. Describe the organizational need without identifiable client details. Any necessary records exchange should be arranged separately.

Can the review lead to staff training?

Yes, training can be discussed if it fits the needs identified. It must be included in the agreed scope or arranged as a separate service.

Is this the same as a compliance determination?

No. The review has an agreed purpose and limits. It does not replace decisions by a payer, regulator, or accrediting organization.

A thoughtful next step

Let’s talk about the work ahead.

Share your priorities, budget, and timeline in the consulting inquiry.

Consulting inquiry