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-000192

Pilar Upfield · ENC-00055 · written by Dr. Greta Kowalczyk (resident) · cosigner Dr. Odette Galloway · status pending

Source document DOC-000192: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Pilar Upfield   MRN: MRN23245859   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Upper GI bleed: continue current management.
2. AKI: trend creatinine, hold nephrotoxins, strict intake and output.
3. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
4. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Greta Kowalczyk   Attending cosign: pending

Open documentation questions on this encounter (2)

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 Acute kidney injury: Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
Evidence and rule trace
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

Only Dr. Odette Galloway can cosign. Sign in (demo).