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Exact Dx synthetic data · demonstration
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.

← Notes awaiting cosign

Pre-cosign check: Progress note DOC-000226

Lena Upfield · ENC-00065 · written by Dr. Camila Oyelaran (resident) · cosigner Dr. Rosalind Quillan · status pending

Source document DOC-000226: Progress note (synthetic)
PROGRESS NOTE (Resident)
Patient: Lena Upfield   MRN: MRN63913217   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.
2. Severe malnutrition: dietitian following, supplements.
3. Diastolic heart failure: diuresis and daily weights; monitor electrolytes.
4. Hypoxemia: supplemental oxygen, wean as tolerated.
5. Anemia: trend hemoglobin.

Resident: Dr. Camila Oyelaran   Attending cosign: pending

Open documentation questions on this encounter (6)

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 blood loss anaemia: Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
    Evidence and rule trace
  • Specificity gap Chronic kidney disease: Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
    Evidence and rule trace
  • Specificity gap Heart failure: Documented “diastolic heart failure” (I50.30); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
    Evidence and rule trace
  • Specificity gap Hyponatraemia: Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.
    Evidence and rule trace
  • Clinical validation gap Malnutrition: Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (chronic illness context), E44.0).
    Evidence and rule trace
  • Clinical judgement required Acute respiratory failure: Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.
    Evidence and rule trace

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