17. Common audit and denial risks

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

• Oral status charted qualitatively (“okay”) without an oral exam or comparison to baseline.
• A decline in intake charted without examining the mouth for a cause.
• An oral lesion, bleeding, or infection noted without action or follow-through (no closed loop).
• Repetitive, cloned oral notes with identical wording and no trajectory.
• Teaching documented as “educated on mouth care” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no infection, lesion, intake, or teaching rationale).