17. Common audit and denial risks

The patterns below are the system-specific failure modes; each maps to Segment 6 (Denial Patterns).

• A device charted in a state word (“intact,” “in place”) with no site, patency, securement, or sterile-care assessment.
• Dressing changes or flushes charted as tasks without technique, site assessment, or patency judgment.
• A site complication noted without measurement, notification, or follow-through (no closed loop).
• Drain or feeding charted without output, character, residual, or tolerance and trajectory.
• Teaching documented as “educated on line care” without learner response or return demonstration.
• A self-managing patient with a stable device charted without an articulated ongoing skilled need.