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A clinical documentation audit you run on your own charts catches gaps before a payer does. This walks through reading a chart in two directions, the focus questions for each document, and the gaps worth looking for first.

A defensible chart is one connected document. The Golden Thread runs from your diagnostic assessment through your discharge summary, and a reviewer should be able to follow it the whole way. Here is how the four documents link, and how to keep it clear the whole way through.