Documentation demonstrates persistent clinical requirements and intensity of services through Day 0-2.
No high-confidence early defensibility gaps detected
These clarifications do not change the chart-level defensibility verdict or score. They are optional opportunities for documentation improvement.
Chart Timeline (Explanatory)
This timeline shows the notes in the chart for reference. It does not score or classify individual notes.CDI Query Suggestions
NOTEThis tool supports clinical documentation clarification and severity capture. It does not determine diagnoses or predict payer outcomes.
CMS Medical Necessity
Level-of-care documentation gaps that may affect CMS medical necessity defensibility. These are separate from diagnosis clarification queries.Audit-Relevant Documentation Signals
These documentation patterns are commonly reviewed during payer audits. Addressing these gaps may help reduce audit exposure.Documentation patterns that may receive additional scrutiny
Documentation Signals Identified
Based on documentation patterns only. Does not represent a payer determination.