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-000394

Mara Dunmore · ENC-00116 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Jalen Carrow · status pending

Source document DOC-000394: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Mara Dunmore   MRN: MRN98911807   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. Malnourished: dietitian following.
3. Congestive heart failure: diuresis and daily weights; monitor electrolytes.
4. Acute respiratory failure with hypoxia: supplemental oxygen, wean as tolerated.
5. Stage 4 sacral pressure ulcer: wound care following, offloading.

Resident: Dr. Noor Halvorsen   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.

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
Clinical judgement required Malnutrition: Clinical judgement required: Only one consensus characteristic documented; two are required.
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 2 L/min, no advanced support.
Evidence and rule trace

Only Dr. Jalen Carrow can cosign. Sign in (demo).