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-000057

Zara Whitlock · ENC-00017 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Kenji Stavros · status pending

Source document DOC-000057: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Zara Whitlock   MRN: MRN32001162   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Malnourished: dietitian following.
3. Heart failure: diuresis and daily weights; monitor electrolytes.
4. Sacral decubitus ulcer: wound care following, offloading.

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 judgement required Heart failure: Clinical judgement required: Only one acute indicator; acuity needs clinical judgement.
Evidence and rule trace
Clinical validation gap Malnutrition: Documented “malnourished” (E46) but the criteria are not met: 4 characteristics assessed and none met.
Evidence and rule trace
Specificity gap Pressure injury: Documented “sacral decubitus ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 3 (L89.153).
Evidence and rule trace

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