17. Common audit and denial risks

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

• A headache or head strike charted qualitatively without characterization, the anticoagulation context, or surveillance.
• A fall with a head strike charted without a documented neuro check or precaution teaching.
• An abnormal finding noted without notification, orders, or follow-through (no closed loop).
• Repetitive, cloned head/scalp notes with identical wording and no trajectory.
• Teaching documented as “educated on head injury” without learner response or return demonstration.
• A stable patient charted without an articulated ongoing skilled need (no surveillance, wound, or teaching rationale).