{"patient_id":"P35","encounter_id":"KE-P35","note_id":"KN-P35-1","signed":false,"ignored_instructions":[],"origin":"clinician","origin_label":"Clinician-typed","origin_note":"as declared by the source system","needs_look":1,"extended":{"on":false,"front":[],"library":[],"banner":"Extended capabilities: published criteria cited by title and restated in our own words, no text reproduced; a licence or permission is needed before commercial use.","title":"Extended capabilities","n":0,"n_hidden":0},"check_current":true,"needs_look_kidney":0,"surfaced":[{"source":"front","family":"malnutrition"},{"source":"kidney","family":"kidney"}],"model":{"off":false,"failed":false,"degraded":false},"run_id":"RUN-00047","replay_hash":"9a7a6063bdc77e15b1a8b9d119f4ba12023d3d4d66aeacd56d8506774940a26c","measurement_replay_hash":"403b3dd211e0b7adbe6d6ecf8a511f367eef41f5a186905f2918e908f7a8a2e2","engine":"kidney-engine 2.0","rules":[{"rule":"ckd_epi_2009@1.0","source":"Levey et al., Ann Intern Med 2009;150:604-12 (2009 eGFR equation, drift check)","url":"https://www.acpjournals.org/doi/10.7326/0003-4819-150-9-200905050-00006"},{"rule":"ckd_epi_2021@1.0","source":"Inker et al., N Engl J Med 2021;385:1737-49 (2021 race-free eGFR equation)","url":"https://www.kidney.org/ckd-epi-creatinine-equation-2021"},{"rule":"kdigo_aki_2012@1.1","source":"KDIGO 2012 guideline, Kidney Int Suppl 2012;2:1-138 (Rec 2.1.1-2.1.2, Table 2)","url":"https://kdigo.org/guidelines/acute-kidney-injury/"},{"rule":"kdigo_ckd_2024@1.1","source":"KDIGO 2024 guideline, Kidney Int 2024;105(4S):S117-S314 (G/A categories, >3 months)","url":"https://kdigo.org/guidelines/ckd-evaluation-and-management/"},{"rule":"kidney_compare@1.1","source":"Two-sided comparison (this tool); ICD-10-CM guideline I.A.19; ACDIS/AHIMA compliant query practice, 2026 update","url":"https://www.cms.gov/medicare/coding-billing/icd-10-codes"},{"rule":"kidney_exclusions@1.0","source":"KDIGO 2024 guideline, limitations of creatinine-based eGFR (muscle mass, pregnancy, kidney replacement); local list","url":"https://kdigo.org/guidelines/ckd-evaluation-and-management/"},{"rule":"lab_units@1.1","source":"KDIGO 2012 and 2024 guidelines, unit conversion (creatinine 1 mg/dL = 88.4 umol/L; ACR 1 mg/mmol = 8.84 mg/g)","url":"https://kdigo.org/guidelines/ckd-evaluation-and-management/"}],"last_replay":null,"library":{"run_id":"LRUN-00047","encounter_id":"KE-P35","note_id":"KN-P35-1","config":"library_default_set@1.1","engine":"library-engine 1.1","replay_hash":"556b6e2205c057cb04f4dd8bacec0015e416b12c5e5d175c16f59d30c28587c2","measurement_replay_hash":"3e7685b517cf116a20bb3d4897158a7f623f414013b7f92b938ce534adcfea04","surfaced":[],"more":[],"extended":[],"extended_on":false,"n_hidden_extended":0,"n_extended_needs":0,"n_needs":0,"limit":3,"dismissed":0,"ctcae_on":false,"draft_label":"Draft definition: pending clinical and coding review","dismiss_reasons":{"addressed_elsewhere":"Already addressed elsewhere in the record","not_representative":"Values not representative (for example acute illness or a lab error)","not_relevant":"Not relevant to this visit","definition_not_applicable":"The definition does not apply to this patient","other":"Other (explain)"}},"findings":[{"family":"kidney","topic":"Kidney filtering rate (eGFR) over time","status":"agrees","label":"Agrees: nothing to do","sentence":"Kidney results 200 days apart are 60 or above (filtering rate 71.8 on 2026-04-26 and 71.8 on 2026-11-12) and the note doesn't mention kidney function.","quote":null,"threshold":"Threshold: filtering rate below 60 on two results at least 90 days apart, none of 60 or more between them.","span":null,"note_mentions":false,"lab_ids":["L-0082","L-0083"]}],"front":{"run_id":"FRUN-00047","cards":[{"family":"malnutrition","topic":"Nutrition (dietitian's assessment)","status":"needs_look","label":"Needs a look","sentence":"The dietitian's assessment (Wren Halden, RD, 2026-11-09) documents 3 characteristics at the severe level and 5 at the moderate level or worse (two are required); the note does not state a nutrition diagnosis.","quote":null,"threshold":"Applies only with a dietitian's nutrition assessment. Six characteristics; at least two are required. Severe: two or more at the severe level. Moderate: two or more at the moderate level or worse. Albumin and prealbumin are not criteria.","span":null,"note_mentions":false,"lab_ids":[],"direction":"UNDER","definition":"front_malnutrition_us_consensus@1.0","reviewed":false,"evidence":[{"text":"Context documented by Wren Halden, RD on 2026-11-09","quote":"chronic illness (pancreatic adenocarcinoma on chemotherapy)","by":"Wren Halden, RD","item":"NA-P35-1"},{"text":"Energy intake: severe level · 50% of estimated needs for 42 days","quote":"about 50% of estimated energy needs for 6 weeks","by":"Wren Halden, RD","item":"NA-P35-1","level":"severe"},{"text":"Weight loss: severe level · 2.8% over 1 month (65 kg on 2026-10-13 to 63.2 kg on 2026-11-12); 7.7% over 3 months (68.5 kg on 2026-08-14 to 63.2 kg on 2026-11-12); 12.2% over 6 months (72 kg on 2026-05-16 to 63.2 kg on 2026-11-12); 14% over 1 year (73.5 kg on 2025-11-12 to 63.2 kg on 2026-11-12)","quote":null,"by":null,"item":"NA-P35-1","level":"severe"},{"text":"Fat loss: moderate level · graded mild","quote":"mild orbital fat loss","by":"Wren Halden, RD","item":"NA-P35-1","level":"moderate"},{"text":"Muscle loss: moderate level · graded moderate","quote":"moderate temporal and clavicular muscle wasting","by":"Wren Halden, RD","item":"NA-P35-1","level":"moderate"},{"text":"Fluid accumulation: not met · graded none","quote":"no edema","by":"Wren Halden, RD","item":"NA-P35-1","level":"not_met"},{"text":"Grip strength: severe level · reduced","quote":"grip strength measurably reduced by hand dynamometer","by":"Wren Halden, RD","item":"NA-P35-1","level":"severe"},{"text":"Low albumin 2.9 g/dL (2026-11-09) and prealbumin 12 mg/dL (2026-11-09): not a criterion in this definition.","quote":null,"by":null,"item":null,"note":true}],"acuity":[],"options":[{"key":"moderate","kind":"wording","requires":"two or more characteristics at the moderate level or worse","shows":"5 at the moderate level or worse","status":"met","status_label":"met","wording":"Moderate (non-severe) malnutrition in the context of chronic illness"},{"key":"severe","kind":"wording","requires":"two or more characteristics at the severe level","shows":"3 at the severe level","status":"met","status_label":"met","wording":"Severe malnutrition in the context of chronic illness"},{"key":"other","kind":"fixed","wording":"Other (I will write it)"},{"key":"unable","kind":"fixed","wording":"Clinically unable to determine"},{"key":"not_supported","kind":"fixed","wording":"Not clinically supported (I will revise the note myself)"}],"chosen":null}],"dismissed":0}}