17. Common audit and denial risks

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

• A genitourinary assessment charted qualitatively (“no complaints”) without the exam, the consent and chaperone note, or comparison to baseline.
• Voiding charted without retention assessment or residual where indicated.
• A scrotal, hernia, or infection finding noted without action or follow-through (no closed loop).
• Repetitive, cloned genitourinary notes with identical wording and no trajectory.
• Teaching documented as “educated on catheter” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no retention, post-op, or teaching rationale).