Clinical Documentation & Compliance Audits

Your Clinical Records Are Your Protection.
Are They Holding Up?

Practice Integrity Dental reviews dental practice charts against the standards auditors and insurance carriers actually apply — so you know what's solid before they do.

For Dental Practice Owners and Office Managers

The documentation gaps that expose your practice aren't visible to your team. They're invisible until they're not.

Most practices believe their charts are in order. They find out otherwise when an auditor does the review instead.

📋

Insurance Denials

Missing documentation is the #1 reason same-day treatment claims get denied. The procedure was done. The chart doesn't prove it.

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Audit Exposure

Insurance carriers and Medicaid programs are auditing more aggressively than ever. Unsigned treatment plans, unlabeled x-rays, incomplete perio charts — these are the things they look for.

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Legal Risk

Incomplete records aren't just a compliance issue. They expose the doctor to legal liability. Signed consents, current medical histories, complete charts — these protect everyone.

We find what your team can't see.

Most dental practices have documentation gaps they don't know about. Practice Integrity Dental reviews your clinical records, identifies what's missing, and delivers a written report with exact findings and correction instructions.

We do NOT do billing, AR cleanup, or practice management. We audit the record. We hand you the fix.

  • Chart notes reviewed against clinical documentation standards
  • X-ray quality, labeling, and appropriateness assessed
  • Consent forms and signed treatment plans verified
  • Medical history compliance confirmed
  • Procedure-to-documentation alignment checked
  • Every gap flagged by chart number, code, and risk level
What We Review

Six categories. Every chart.

  • Chart notes and clinical detail
  • X-ray quality and labeling standards
  • Treatment plans and consent documentation
  • Medical history compliance and medication lists
  • Perio charting, SRP, crown, endo, and extraction records
  • Missing documentation flagged by risk level

Strictly clinical documentation. No billing language. No financial auditing. The record is the scope.

What's included in every audit.

Seven categories reviewed systematically. Every chart examined. Every gap documented.

01

Chart Note Review

Diagnosis coding accuracy, clinical detail sufficiency, and procedure-to-note alignment across every chart reviewed.

02

X-Ray Quality Assessment

Image quality, positioning, labeling standards, and periapical vs. bitewing appropriateness per ADA guidelines.

03

Treatment Plan & Consent Check

Signed treatment plans, financial consent forms, and informed consent documentation — verified by chart.

04

Medical History Compliance

MH updates within required timeframe, medication list accuracy, and alert flags documented appropriately.

05

Procedure-to-Documentation Alignment

Perio charting matched to SRP records, crown and endo documentation reviewed, extraction records verified complete.

06

Missing Documentation Identification

Every gap flagged by chart number, procedure code, and risk level — so your team knows exactly what to fix first.

07

Implant Placement Records

Surgical records, prosthetic planning documentation, bone quality assessment, post-operative notes, and implant-specific consent. Implant procedures carry heightened documentation requirements and are a priority target in carrier audits.

Every audit delivers five written outputs.

Not a conversation. A document. Clear findings, clear corrections, ready for your team to act on.

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Compliance Score

Low / Moderate / High Risk rating with plain-language explanation of what the score means for your practice.

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Missing Documentation Report

Tabular list of every gap found, cross-referenced to procedure codes and chart numbers.

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At-Risk Chart List

Prioritized list ranked by audit exposure — so you know which charts to address first and why.

Correction Checklist

Numbered action items with step-by-step instructions and urgency ranking for each finding.

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Team Training Recommendations

What to teach, what the new standard should be, and how to implement it across your documentation workflow.

You're not watching the documentation. We are.

The Monthly Audit Retainer keeps your compliance exposure low all year. Every month, we review a sample of charts and deliver a written report on the 5th. No meetings required.

Start Your Monthly Retainer
$997 /month
  • 25 charts reviewed per month
  • Written monthly report delivered on the 5th
  • Quarterly compliance trend summary
  • Email support with 48-hour response
  • Fully remote — no on-site visits

Cancel anytime. No annual contracts.

Three tiers. Scope scales with your practice.

Every audit is a one-time engagement. No subscription required unless you want the retainer.

Starter
$997
25 charts reviewed
  • Chart note review
  • X-ray quality assessment
  • Treatment plan & consent check
  • Missing documentation report
  • At-risk chart list (top 5)
  • Correction checklist
  • Written findings report
  • 30-minute results call

Best for: Solo practice or internal review prep

Get Started
Premium
$3,497
100 charts reviewed
  • Everything in Standard
  • Credentialing review
  • Carrier-specific compliance assessment
  • Audit-ready documentation file prep
  • Practice-wide trend analysis
  • Custom correction roadmap
  • 2× 60-minute calls
  • 90-day email support

Best for: Active audit notice or multi-location review

Get Started

Need something specific? Add it to any audit.

Appeal Letter Drafting

$297

Documentation-based appeal letters drafted against the specific findings from your audit. Ready to submit.

Audit Prep Package

$697

Full pre-audit preparation — chart review, gap remediation guidance, and a carrier-ready documentation file before the audit date.

Credentialing Repair

$497

Credentialing file review and documentation correction to bring your provider records into compliance.

Monthly Audit Retainer

$997/mo

Ongoing monthly chart review with written report delivered on the 5th. 25 charts per month, fully remote.

Your team can run internal audits between retainer reviews.

Practical documentation tools built to the same standards we audit against. Download and implement.

Clinical Documentation Audit Checklist

Step-by-step chart review across all documentation categories — built for front-office self-audits.

$49

Chart Note Template Set

Procedure-specific note templates aligned with carrier documentation standards. Fills the gaps before they become findings.

$79

X-Ray Quality Standards Guide

Image quality benchmarks, labeling standards, and ADA positioning guidelines your team can apply immediately.

$39

Treatment Plan & Consent SOP

Standard operating procedures for consent documentation, treatment plan signature workflow, and informed consent requirements.

$59

Full Documentation Bundle

All 4 products combined — audit checklist, note templates, x-ray guide, and consent SOP

$199
Save $27 vs. individual

Simple. Systematic. Delivered in writing.

No on-site visits. No drawn-out timelines. You provide access, we do the review, you receive the report.

01

Book & Onboard

Complete the intake form and provide read-only PMS access or a chart export. We handle the rest from there.

02

We Audit

We review every chart systematically across all documentation categories — chart notes, x-rays, consents, medical histories, and procedure alignment.

03

You Receive Your Report

Written findings with risk level, corrections, and training notes. A call is included if you want to walk through it together.

Book Your Documentation Audit

Practices that caught it before the auditor did.

Documentation gaps don't surface until they cost you. These practices found theirs first.

We had 30 days to prepare for a carrier audit. Practice Integrity Dental found 18 charts with unsigned treatment plans and incomplete perio records. We corrected every one before the auditor reviewed a single record. They passed the audit.

Dr. R. Chambers
Multi-provider practice, Florida — received audit notice

I thought my documentation was solid. Turns out half my same-day SRP claims didn't have perio charting to support them. That's $14,000 in claims that could have been denied or clawed back. Practice Integrity Dental found it before anyone else did.

Dr. M. Torres
Solo practice owner, Texas

I've been in practice management for 12 years and I still couldn't see what Practice Integrity Dental saw. The x-ray labeling issue alone — I had no idea we were labeling bitewings wrong per ADA standards. Fixed in one training session.

S. Nguyen
Office Manager, multi-location group practice

The documentation is the proof. Make sure it holds up.

Every gap we find is a gap an auditor could find first. Let's close them before they matter.