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-000358

Dmitri Greaves · ENC-00106 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Cyrus Ellingham · status pending

Source document DOC-000358: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Dmitri Greaves   MRN: MRN92245369   Hospital day 5

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

Resident: Dr. Noor Halvorsen   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: Criteria support Chronic kidney disease stage 3a (N18.31); no corresponding diagnosis is documented.
Evidence and rule trace
Clinical validation gap Heart failure: Documented “acute on chronic systolic heart failure” (I50.23) is more specific than the criteria support (Chronic systolic (HFrEF) heart failure, I50.22).
Evidence and rule trace
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: Documented “malnourished” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (chronic illness context) (E44.0).
Evidence and rule trace

Only Dr. Cyrus Ellingham can cosign. Sign in (demo).