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-000582

Vera Penhallow · ENC-00173 · written by Dr. Noor Halvorsen (resident) · cosigner Dr. Rosalind Quillan · status pending

Source document DOC-000582: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Vera Penhallow   MRN: MRN26255814   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Systolic heart failure: diuresis and daily weights; monitor electrolytes.
3. Hypoxemia: supplemental oxygen, wean as tolerated.

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 “systolic heart failure” (I50.20); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
Evidence and rule trace
Specificity gap Hyponatraemia: Criteria support Hyponatraemia (profound) (E87.1); no corresponding diagnosis is documented.
Evidence and rule trace
Specificity gap Acute respiratory failure: Documented “hypoxemia” (R09.02); criteria support the more specific Acute respiratory failure with hypoxia (J96.01).
Evidence and rule trace

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