Audit Rules

Audit rules are your clinic's own documentation checks. Every active rule runs on the notes it covers when they are signed, after an addendum and nightly, beside the built-in visit checks. See Note audits for what happens to a finding.

Open Setup > Audit Rules to keep your rules. Managing them needs the Setup: Clinical Manage permission.

Starting from a starter pack#

Click Starter Packs to see the packs NeatPractice wrote from common payer and clinic guidance. Core packs cover every discipline; a discipline module's pack covers only that discipline's notes and appears while your clinic has the module. Click Install to copy a pack's rules into your clinic. You can then edit or archive them like your own.

Rules that check your templates' answers install as drafts: point them at the right answer labels and templates, then switch them on.

Writing a rule#

Click New Rule. The dialog has four sections.

Rule

• Name and Description: shown to authors and reviewers with each finding, so say what to write instead. Keep patient details out of them.
• Checks: what the rule looks at.
  • Words and phrases: Words not allowed fail the note when any one appears (whole words, any case), and Words required fail it when one is missing.
  • Length: a minimum number of words, or of sentences for each hour of the session (3 per hour asks a 90 minute session for 5).
  • Required answers: answers whose label contains the words you list, such as Assessment or Plan, must be filled.
  • AI guideline: a yes or no question the AI answers for each covered note. See AI guideline rules.
• Source and Tags: where the rule comes from, in your words, and tags to group rules.

Applies to

• Disciplines, Templates and Payers (the visit's payer). Leave a list empty to cover everything.
• Codes, Credential levels of the author, and From and To dates of service narrow it further.

Enforcement

• Severity: what a failure costs the audit score (low 1, medium 2, high 5, critical 20).
• A failure: Advisory, Block signing, Hold charges or Send to QA. An AI guideline rule cannot block signing.
• Active: only active rules audit notes.

Samples

Add two to six made-up notes, each marked Should pass or not. Never paste a real note.

Testing a rule#

Click Test Rule to run the rule, as it stands in the dialog, on its samples. The result shows the pass rate and whether each sample came out as expected. A words or length rule can be switched on only when it has at least one sample it should pass and one it should fail, and every sample comes out as expected. Required answers rules read the note's template, so samples do not apply to them. AI guideline rules are not tried on samples, since each try would spend credits; check a draft note with Check Note instead.

AI guideline rules#

Some guidelines need judgment, such as "Does the note describe the skilled care the clinician gave?". An AI guideline rule asks the AI that question about each note it covers. The AI answers met, not met, not applicable or uncertain, explains why in a sentence or two, and quotes the words of the note it relied on.

AI guideline rules run only while AI note audits is turned on in Documentation Rules. When you choose AI guideline under Checks, the dialog asks for:

• Question for the AI: the yes or no question. It goes to the AI with every note, so keep patient details out.
• Passes when and Fails when: what a note needs to show, and what makes it fail.
• The AI may read: the parts of the note the AI receives: Note sections, Goal data, Plan goals, Codes and minutes, Discipline data (such as programs and session data from a discipline module) and Payer. Leave it empty for the note sections only.
• Not applicable when (optional): when the AI should skip the rule, such as an evaluation-only session.

Before a note reaches the AI, patient, provider and contact names are replaced with placeholders, and dates, chart numbers and diagnosis codes are never sent. A verdict the AI cannot back with a quote from the note is marked Uncertain so a reviewer looks at it.

Versions and history#

Every save adds a new version; audits keep pointing at the version they used. Add a note in What changed when you edit. Click History on a rule to see every version, who saved it and when.

Rules are never deleted. Archive stops a rule from auditing notes and closes its open findings; Restore brings it back as a draft. Turn on Show Archived from the page menu to list archived rules.

Rules set elsewhere#

Similarity with earlier notes and whether the visit checks block signing are set per discipline in Documentation Rules. Words a role may never use can also be kept as Restricted Phrases, which always block signing.