17. Common audit and denial risks

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

• Vision charted qualitatively (“okay,” “worse”) without functional assessment or comparison to baseline.
• Eye drops charted as a fact without technique assessment or adherence.
• An acute visual change noted without onset, pattern, or escalation (no closed loop).
• Repetitive, cloned eye notes with identical wording and no trajectory.
• Teaching documented as “educated on eye care” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no teaching, surveillance, or safety rationale).