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-000278

Keira Ravensworth · ENC-00081 · written by Dr. Priya Thorne (resident) · cosigner Dr. Gideon Zeller · status pending

Source document DOC-000278: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Keira Ravensworth   MRN: MRN37040672   Hospital day 6

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Class 1 obesity: counsel on weight.
3. Acute kidney injury: trend creatinine, hold nephrotoxins, strict intake and output.
4. Congestive heart failure: diuresis and daily weights; monitor electrolytes.
5. Hypoxia: supplemental oxygen, wean as tolerated.
6. Acute blood loss anemia: trend hemoglobin, transfuse if needed.

Resident: Dr. Priya Thorne   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.

Specificity gap Heart failure: Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
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. Gideon Zeller can cosign. Sign in (demo).