Physician Query Library

Patient has documented infection with SIRS criteria (fever, elevated WBC, tachycardia) but no sepsis diagnosis

Patient has elevated creatinine or decreased urine output but no AKI diagnosis

Patient requires supplemental oxygen or ventilatory support but no respiratory failure diagnosis

Patient has very low albumin, significant weight loss, or BMI <18.5 but no malnutrition diagnosis or severity specified

Patient has very low GFR or is on dialysis but CKD stage not documented

Patient has BMI ≥40 but only 'obesity' documented without 'morbid' specification

Patient has pneumonia with history of dysphagia/aspiration but type not specified

Patient has COPD exacerbation requiring high-flow oxygen but respiratory failure not documented

Patient has CHF exacerbation with pulmonary edema but 'acute decompensated' not documented

Stroke patient has severe paralysis but documented as 'hemiparesis' or 'weakness' instead of 'hemiplegia'

Patient has COPD with increased dyspnea and sputum but no respiratory failure documented

Patient has eGFR 15-29 but CKD stage not documented

Patient has low albumin or weight loss but severity not specified

Patient has CHF history but acuity not documented

Stroke patient has weakness but severity not specified

Patient has pneumonia but type not specified

Patient has UTI with systemic symptoms but no sepsis

Patient has low hemoglobin but severity not documented

Patient has pressure injury but stage not documented

Patient has diabetes with complications but not fully documented

Patient admitted with 'CHF' documented but lacking specificity for systolic vs. diastolic, acute vs. chronic

Patient has 'diabetes' documented without type specification or complication details

Patient has CKD documented without stage specification

Patient admitted with 'CVA' or 'stroke' without specificity

Patient has COPD documented but unclear if acute exacerbation is present

Comorbidity is documented in history but unclear if actively treated during IRF stay

Patient has hypertension but unclear if complications are present

Patient has anemia documented without type or severity

Patient has history of depression but unclear if currently active and treated

Lab results show low albumin but no malnutrition diagnosis documented

Patient has consistently elevated blood glucose but no diabetes diagnosis

Patient requires supplemental oxygen but no respiratory diagnosis documented

Nursing notes describe wound with signs of infection but no diagnosis documented

Patient has MI documented but unclear if recent or historical

Patient has DVT documented but unclear if current episode or past history

Patient has cancer documented but unclear if currently active or in remission

Patient on anticoagulation but indication not documented

Patient receiving insulin but no diabetes diagnosis documented

Patient on antidepressants/antipsychotics but no mental health diagnosis

Patient on modified diet but no dysphagia diagnosis documented

Patient requires incontinence care but no diagnosis documented

Patient shows signs of surgical site infection but no diagnosis documented

Patient has low hemoglobin post-surgery but no anemia diagnosis