P01 KE-P01 · outpatient visit

One row per condition family: what the record supports under the published definition, what the note states, the visit's diagnosis entries, and an assessment. Codes are coded from the signed documentation; the software never assigns one.

Library check LRUN-00001 · library_default_set@1.0 · library-engine 1.0 · replay 7e1a90ec93ece149… · Data (JSON)

Draft query: Hypertension

Blocked by the query linter

A non-leading clarification request: clinical indicators with their sources, an open question, several options plus "other" and "unable to determine". No code and no payment word; the same indicators cannot be queried twice.

DOCUMENTATION QUERY (draft) for KE-P01 · blood_pressure
Title: Clarification request: blood pressure readings
Encounter: KE-P01   Patient: P01   To: author of the draft note
From: (no named sender: sign in to send)
Date: 2026-11-13   Rule versions: nhlbi_bp_categories@1.0, library_default_set@1.0   Check run: LRUN-00001

Clinical indicators from the health record:
- Diastolic 78 mmHg (2026-11-12 10:05) [measurement LM-P01-04]
- Systolic 132 mmHg (2026-11-12 10:05) [measurement LM-P01-03]

Question:
Based on your independent clinical judgement, how would you describe the clinical significance of the blood pressure readings listed above?

Response options (select one or write your own):
( ) Hypertension
( ) Elevated blood-pressure reading, without diagnosis of hypertension
( ) Not clinically significant for this encounter
( ) Other (please specify): ____________
( ) Unable to determine

Please respond based on your independent clinical judgement. Any response, including "unable to determine", is acceptable. This query and your response are kept as part of the health record.

error · no_sender: A query needs a named human sender (sign in).

Condition families for this encounter (2)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Hypertension measured	`nhlbi_bp_categories@1.0` Draft · pending review High blood pressure stage 1: 130 to 139 systolic or 80 to 89 diastolic bp diastolic office 78 mmHg 2026-11-12 10:05 · LM-P01-04 bp systolic office 132 mmHg 2026-11-12 10:05 · LM-P01-03 Window: 365 days before the check. Another published definition (`esc2024_office_bp@1.0`) gives: Elevated BP: office 120–139 systolic or 70–89 diastolic. Citation Adult blood pressure categories: normal, elevated, stage 1, stage 2 (NHLBI, as in the 2017/2025 ACC/AHA guidelines) nhlbi_bp_categories@1.0 Normal: Less than 120 systolic AND Less than 80 diastolic; Elevated: 120 to 129 AND Less than 80; Stage 1: 130 to 139 OR 80 to 89; Stage 2: 140 or higher OR 90 or higher; Hypertensive Crisis: Higher than 180 OR Higher than 120 National Heart, Lung, and Blood Institute (U.S. National Institutes of Health), High Blood Pressure — Diagnosis (2025) · Blood pressure categories table · source Contested: European guidelines define hypertension at 140/90 (ESC 2024, encoded separately as esc2024_office_bp) while AHA/ACC use 130/80. Not encoded: Measurement technique (seated, rested, correct cuff), averaging of several readings per visit, out-of-office (home, ambulatory) thresholds, white-coat and masked hypertension are not encoded. The 2025 AHA/ACC guideline's own table was not opened; the categories are taken from the NHLBI page. Children and adolescents are not covered (population limited to 18 and older as an interpretation).	Not stated	None entered	The record supports it; neither stated in the note nor entered Draft a query
Code-family reference: Hypertension Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `I10` Essential (primary) hypertension: distinguishes essential (primary) hypertension (one code); hypertension with heart or kidney disease uses I11-I13 (1 codes in the category). `I10` Essential (primary) hypertension `R03` Abnormal blood-pressure reading, without diagnosis: distinguishes R03.0 elevated blood-pressure reading without diagnosis of hypertension; R03.1 nonspecific low reading (2 codes in the category). `R03.0` Elevated blood-pressure reading, without diagnosis of hypertension `R03.1` Nonspecific low blood-pressure reading Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Severe hypercholesterolaemia (LDL) measured	`aha2018_severe_hypercholesterolaemia@1.0` Draft · pending review Not assessable: no usable ldl_cholesterol measurement Window: 730 days before the check. Another published definition (`atp3_ldl@1.0`) gives: not assessable. Citation Severe hypercholesterolaemia, LDL-C ≥190 mg/dL (2018 AHA/ACC cholesterol guideline) aha2018_severe_hypercholesterolaemia@1.0 Severe Hypercholesterolemia (LDL-C ≥190 mg/dL [≥4.9 mmol/L]) American Heart Association / American College of Cardiology and partner societies, 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol (2018) · Section 4.2 heading; Top 10 Take-Home Message 4 · source Not encoded: 'Primary' (excluding secondary causes) is not assessed. Age 20-75 limits of the treatment recommendation are not encoded (only ≥20). Persistence or untreated status of the LDL is not checked.	Hyperlipidemia	None entered	Cannot be assessed no_value
Code-family reference: Severe hypercholesterolaemia (LDL) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E78` Disorders of lipoprotein metabolism and other lipidemias: distinguishes pure hypercholesterolaemia, unspecified or familial (homozygous, heterozygous, unspecified) (18 codes in the category). `E78.00` Pure hypercholesterolemia, unspecified `E78.010` Homozygous familial hypercholesterolemia [HoFH] `E78.011` Heterozygous familial hypercholesterolemia [HeFH] `E78.019` Familial hypercholesterolemia, unspecified `E78.1` Pure hyperglyceridemia `E78.2` Mixed hyperlipidemia `E78.3` Hyperchylomicronemia `E78.41` Elevated Lipoprotein(a) `E78.49` Other hyperlipidemia `E78.5` Hyperlipidemia, unspecified `E78.6` Lipoprotein deficiency `E78.70` Disorder of bile acid and cholesterol metabolism, unspecified `E78.71` Barth syndrome `E78.72` Smith-Lemli-Opitz syndrome `E78.79` Other disorders of bile acid and cholesterol metabolism `E78.81` Lipoid dermatoarthritis `E78.89` Other lipoprotein metabolism disorders `E78.9` Disorder of lipoprotein metabolism, unspecified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).