Third-party audits will often explore specific parts of the medical record looking for disagreements in the documentation. As an example of such a disagreement, consider a past medical history and ROS showing all systems to be negative while the active medication and/or problem lists suggest otherwise. Or, a past ocular history as negative despite cataract surgery being documented elsewhere in the record.
It is easy to look at these in isolation and say, “that’s no big deal.” A third party might have the same response. However, the more instances of these disagreements found in an audit, the more the auditor will begin to question the quality of the provider’s documentation and also if the auto-populate feature was used without review (e.g., default normal button).
It is best to avoid those questions completely by making sure that all elements of the record are in agreement prior to signing the encounter.