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-000297

Lena Northam · ENC-00087 · written by Dr. Elena Nakashima (resident) · cosigner Dr. Kenji Stavros · status pending

Source document DOC-000297: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Lena Northam   MRN: MRN97875486   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Congestive heart failure: diuresis and daily weights; monitor electrolytes.
3. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
4. Anemia: trend hemoglobin.

Resident: Dr. Elena Nakashima   Attending cosign: pending

Open documentation questions on this encounter (4)

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 3a (N18.31).
Evidence and rule trace
Specificity gap Heart failure: Documented “congestive heart failure” (I50.9); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
Evidence and rule trace
Specificity gap Obesity: Criteria support Obesity, class 3 (E66.813); no corresponding diagnosis is documented.
Evidence and rule trace
Clinical validation gap Acute respiratory failure: Documented “acute respiratory failure with hypoxia” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 1 L/min, no advanced support.
Evidence and rule trace

Only Dr. Kenji Stavros can cosign. Sign in (demo).