Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

Pre-cosign check: Progress note DOC-000003

Teodora Vance · ENC-00001 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Cyrus Ellingham · status pending

Source document DOC-000003: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Teodora Vance   MRN: MRN98588461   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.
2. CKD: renally dose medications.
3. Renal insufficiency: trend creatinine, avoid nephrotoxins.
4. CHF: diuresis and daily weights; monitor electrolytes.
5. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.

Resident: Dr. Noor Halvorsen   Attending cosign: pending

Open documentation questions on this encounter (4)

Advisory only. You can cosign now; these stay with the CDI team. They come from the published criteria, not from a model.

Specificity gap Acute kidney injury: Documented “renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 2) (N17.9).
Evidence and rule trace
Specificity gap Chronic kidney disease: Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 3b (N18.32).
Evidence and rule trace
Specificity gap Heart failure: Documented “CHF” (I50.9); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
Evidence and rule trace
Clinical validation gap Acute respiratory failure: Documented “acute hypoxic respiratory failure” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 2 L/min, no advanced support.
Evidence and rule trace

Only Dr. Cyrus Ellingham can cosign. Sign in (demo).