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-000017

Gideon Merriweather · ENC-00005 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Kenji Stavros · status pending

Source document DOC-000017: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Gideon Merriweather   MRN: MRN68518928   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. Class 3 obesity: counsel on weight.
3. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
4. Hyponatremia: trend sodium.

Resident: Dr. Noor Halvorsen   Attending cosign: pending

Open documentation questions on this encounter (3)

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

Clinical validation gap Hyponatraemia: Documented “hyponatremia” (E87.1) but the criteria are not met: All sodium values 135 or above (lowest 138).
Evidence and rule trace
Clinical validation gap Obesity: Documented “class 3 obesity” (E66.813) conflicts with what the criteria support (Obesity, class 1, E66.811).
Evidence and rule trace
Clinical validation gap Acute respiratory failure: Documented “acute respiratory failure with hypoxia” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 94%), oxygen no more than 0 L/min, no advanced support.
Evidence and rule trace

Only Dr. Kenji Stavros can cosign. Sign in (demo).