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-000091

Sana Ingram · ENC-00027 · written by Dr. Camila Oyelaran (resident) · cosigner Dr. Jalen Carrow · status pending

Source document DOC-000091: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Sana Ingram   MRN: MRN52022739   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Worsening renal function: trend creatinine, avoid nephrotoxins.
3. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

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.

Specificity gap Acute kidney injury: Documented “worsening renal function” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).
Evidence and rule trace
Clinical validation gap Chronic kidney disease: Documented “CKD stage 4” (N18.4) conflicts with what the criteria support (Chronic kidney disease stage 3b, N18.32).
Evidence and rule trace
Specificity gap Pressure injury: Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.
Evidence and rule trace

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