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-000190

Elena Okafor · ENC-00054 · written by Dr. Greta Kowalczyk (resident) · cosigner Dr. Wes Merriweather · status pending

Source document DOC-000190: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Elena Okafor   MRN: MRN76087701   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Malnourished: dietitian following.

Resident: Dr. Greta Kowalczyk   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 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 Malnutrition: Documented “malnourished” (E46); criteria support the more specific Severe protein-calorie malnutrition (acute illness context) (E43).
Evidence and rule trace
Clinical validation gap Sepsis: Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.
Evidence and rule trace

Only Dr. Wes Merriweather can cosign. Sign in (demo).