What information should you expect to find in a medical record when auditing evaluation and management services?

In auditing evaluation and management (E/M) services, it is essential to find comprehensive documentation that supports the services provided to the patient. One critical component of this is patient identification and physician orders.

Patient identification information ensures that the medical record is accurately attributed to the correct individual, which is vital for maintaining proper medical history, treatment plans, and billing practices. This information often includes demographics such as name, date of birth, and insurance details.

Additionally, physician orders are crucial as they reflect the healthcare provider's clinical decisions, treatments, and tests necessary for patient care. Orders for laboratory tests, imaging studies, or referrals are integral to understanding the scope of the patient's evaluation and management. Such documentation supports coding accuracy and compliance with regulatory requirements during audits.

In contrast, the other options do not directly pertain to the essential elements required for auditing E/M services. The physician's schedule and appointments may provide context but do not substitute for detailed clinical documentation. Insurance claims and appeals information relate to the billing process rather than the clinical evaluation, and patient social media interactions are generally considered irrelevant and unprofessional in the context of clinical documentation.

Thus, the presence of patient identification and physician orders is fundamental in validating the clinical services provided and ensuring compliance with E