17. Common audit and denial risks

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

• Bleeding or anemia charted qualitatively (“no bleeding,” “pale”) without assessment, context, or comparison to baseline.
• A fever in an immunosuppressed patient charted without recognizing its urgency.
• New bruising, bleeding, or anemia noted without action or follow-through (no closed loop).
• Repetitive, cloned hematologic notes with identical wording and no trajectory.
• Teaching documented as “educated on bleeding” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no surveillance, precaution, or teaching rationale).