17. Common audit and denial risks

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

• Neck status charted qualitatively (“okay”) without an exam or comparison to baseline.
• Thyroid medication charted without symptom surveillance or coordination.
• A mass, incision, or post-operative sign noted without action or follow-through (no closed loop).
• Repetitive, cloned neck notes with identical wording and no trajectory.
• Teaching documented as “educated on thyroid” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no surveillance, post-op, or teaching rationale).