AI in Clinical Auditing: Improving Electronic Medical Record Integrity

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Accurate and well-supported documentation is essential to reimbursement integrity, survey preparedness, and overall quality performance in skilled nursing homes. With increasing regulatory oversight and the ongoing complexity of the Patient-Driven Payment Model (PDPM), relying solely on retrospective, manual chart audits may leave gaps in identifying documentation risk.

This session examines the role of Artificial Intelligence (AI) in strengthening clinical auditing practices across therapy, nursing, and Minimum Data Set (MDS) documentation. Intended for Rehab Directors, Directors of Nursing, Compliance professionals, and MDS coordinators, the course reviews how AI-supported tools can assist in identifying documentation discrepancies, validating skilled need, highlighting potential PDPM vulnerabilities, and improving interdisciplinary consistency within the Electronic Medical Record (EMR).

Participants will explore practical applications of AI as a clinical decision-support resource that enhances, rather than replaces, professional judgment. Emphasis will be placed on improving audit efficiency, supporting documentation accuracy, and maintaining compliance standards in preparation for survey and payer review.

CE Information:

• This program has been submitted but not yet approved for Continuing Education for 1.0 total participation hours by NAB/NCERS.
• To receive continuing education credit for LeadingAge PA-sponsored webinars, attendees must register under their name, participate through the link supplied after registering and complete the evaluation after the webinar.

Target Audience:

Rehab Directors, Directors of Nursing, Compliance professionals, and MDS coordinators

Event Objectives:

• Explain how AI functions in clinical chart auditing and EMR review within skilled nursing settings and how it identifies compliance risks.
• Analyze high-risk documentation areas and discrepancies across therapy, nursing, and MDS that impact PDPM accuracy, survey outcomes, reimbursement, and audit vulnerability.
• Design a strategy to integrate AI-supported auditing into existing QA, QAPI, and compliance programs, including workflow, data governance, and staff adoption considerations.

Speaker Bios:

Julie Gala, Vice President of Clinical Strategies, HealthPRO-Heritage

Julie Gala is the Vice President of Clinical Strategies and a speech-language pathologist at HealthPRO-Heritage. She is a RAC-CT and PAC-educated clinical leader who oversees and aligns all teams under a unified clinical strategies framework. Gala leads national clinical initiatives, serves as committee lead for NARA and Advion, and is known for translating complex regulatory and reimbursement requirements into practical, scalable solutions. Her work focuses on advancing clinical excellence, operational efficiency, and readiness for value-based care across diverse care settings.