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-000060

Rosalind Upfield · ENC-00018 · written by Dr. Camila Oyelaran (resident) · cosigner Dr. Jalen Carrow · status pending

Source document DOC-000060: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Rosalind Upfield   MRN: MRN70259788   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Class 2 obesity: counsel on weight.
3. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
4. Hyponatremia: trend sodium.
5. Acute blood loss anemia: trend hemoglobin, transfuse if needed.
6. Sacral decubitus ulcer: wound care following, offloading.

Resident: Dr. Camila Oyelaran   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 Acute blood loss anaemia: Clinical judgement required: Haemoglobin fell 1.4 g/dL without transfusion (between 1 and 2 g/dL).
Evidence and rule trace
Specificity gap Chronic kidney disease: Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
Evidence and rule trace
Specificity gap Pressure injury: Documented “sacral decubitus ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, unstageable (L89.150).
Evidence and rule trace

Only Dr. Jalen Carrow can cosign. Sign in (demo).