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-000212

Mara Pemberton · ENC-00061 · written by Dr. Elena Nakashima (resident) · cosigner Dr. Rosalind Quillan · status pending

Source document DOC-000212: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Mara Pemberton   MRN: MRN24952443   Hospital day 6

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Acute on chronic systolic heart failure: diuresis and daily weights; monitor electrolytes.
3. Hyponatremia: trend sodium.

Resident: Dr. Elena Nakashima   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 Hyponatraemia: Clinical judgement required: Low sodium without documented treatment or repeat values; clinical significance is a clinician judgement.
Evidence and rule trace
Specificity gap Malnutrition: Criteria support Moderate (non-severe) protein-calorie malnutrition (acute illness context) (E44.0); no corresponding diagnosis is documented.
Evidence and rule trace
Specificity gap Sepsis: Documented “sepsis” (A41.9); criteria support the more specific Sepsis with septic shock (R65.21).
Evidence and rule trace

Only Dr. Rosalind Quillan can cosign. Sign in (demo).