17. Common audit and denial risks

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

• Ambulation or transfers charted as tasks (“walked in hall,” “transferred”) with no strength grade, distance, assist level, or safety judgment.
• Strength or range of motion described qualitatively (“good,” “limited”) without grading or comparison to baseline.
• A functional decline or fall noted without notification, orders, or therapy coordination (no closed loop).
• Repetitive, cloned mobility notes with identical wording and no trajectory.
• Teaching documented as “educated on exercises” without learner response or return demonstration.
• Reinforcement of therapy with no articulated nursing skilled need, where the visit duplicates rather than complements PT.