17. Common audit and denial risks

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

• A perineal skin assessment charted qualitatively (“skin okay”) without the exam, the consent and chaperone note, or comparison to baseline.
• A perineal skin problem charted without distinguishing dermatitis from a pressure injury.
• A wound, infection, or device-site finding noted without action or follow-through (no closed loop).
• Repetitive, cloned perineal-skin notes with identical wording and no trajectory.
• Teaching documented as “educated on skin care” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no breakdown risk, wound, or teaching rationale).