P02 KE-P02 · 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-00002 · library_default_set@1.0 · library-engine 1.0 · replay 823d08e0e0d974b0… · Data (JSON)

Condition families for this encounter (2)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Obesity / overweight / underweight (body-mass index) measured	`cdc_adult_bmi@1.0` Draft · pending review Criteria not met: Healthy weight: 18.5 to less than 25 bmi 24 kg/m2 2026-11-12 11:05 · LM-P02-01 Window: 365 days before the check. Another published definition (`who_adult_bmi@1.0`) gives: BMI below 25. Citation Adult BMI categories: underweight, healthy weight, overweight, obesity classes 1-3 (CDC) cdc_adult_bmi@1.0 Underweight: Less than 18.5; Healthy Weight: 18.5 to less than 25; Overweight: 25 to less than 30; Obesity: 30 or greater; Class 1 Obesity: 30 to less than 35; Class 2 Obesity: 35 to less than 40; Class 3 Obesity (Severe Obesity): 40 or greater Centers for Disease Control and Prevention, Adult BMI Categories (2024) · Adult BMI categories table · source Contested: BMI cut-offs are population-specific (WHO 2004 expert consultation proposed lower action points for Asian populations; not opened) and BMI does not measure adiposity directly; the CDC page applies the categories 'regardless of age, sex, or race' for adults. Not encoded: The CDC page states no exception for pregnancy, athletes or ethnicity; population-specific cut-offs (for example lower thresholds proposed for Asian populations) are not encoded. BMI is a screening measure (CDC); obesity as a disease (for example the 2025 Lancet Commission 'clinical obesity') needs other assessment. BMI is taken as recorded; it is not computed from weight and height.	Not stated	`E66.9` Obesity, unspecified (visit diagnosis list (synthetic))	Entered or stated without support in the record Draft a query
Code-family reference: Obesity / overweight / underweight (body-mass index) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E66` Overweight and obesity: distinguishes overweight (E66.3), obesity class 1/2/3 (E66.811-E66.813), morbid obesity due to excess calories or with alveolar hypoventilation, drug-induced, other, unspecified (10 codes in the category). `E66.01` Morbid (severe) obesity due to excess calories `E66.09` Other obesity due to excess calories `E66.1` Drug-induced obesity `E66.2` Morbid (severe) obesity with alveolar hypoventilation `E66.3` Overweight `E66.811` Obesity, class 1 `E66.812` Obesity, class 2 `E66.813` Obesity, class 3 `E66.89` Other obesity not elsewhere classified `E66.9` Obesity, unspecified `Z68` Body mass index [BMI]: distinguishes BMI value bands for adults (Z68.1-Z68.45) and percentile bands for paediatrics (Z68.5-) (33 codes in the category). `Z68.18` Body mass index [BMI] 18.4 or less, adult `Z68.19` Body mass index [BMI] 18.5-19.9, adult `Z68.20` Body mass index [BMI] 20.0-20.9, adult `Z68.21` Body mass index [BMI] 21.0-21.9, adult `Z68.22` Body mass index [BMI] 22.0-22.9, adult `Z68.23` Body mass index [BMI] 23.0-23.9, adult `Z68.24` Body mass index [BMI] 24.0-24.9, adult `Z68.25` Body mass index [BMI] 25.0-25.9, adult `Z68.26` Body mass index [BMI] 26.0-26.9, adult `Z68.27` Body mass index [BMI] 27.0-27.9, adult `Z68.28` Body mass index [BMI] 28.0-28.9, adult `Z68.29` Body mass index [BMI] 29.0-29.9, adult `Z68.30` Body mass index [BMI] 30.0-30.9, adult `Z68.31` Body mass index [BMI] 31.0-31.9, adult `Z68.32` Body mass index [BMI] 32.0-32.9, adult `Z68.33` Body mass index [BMI] 33.0-33.9, adult `Z68.34` Body mass index [BMI] 34.0-34.9, adult `Z68.35` Body mass index [BMI] 35.0-35.9, adult `Z68.36` Body mass index [BMI] 36.0-36.9, adult `Z68.37` Body mass index [BMI] 37.0-37.9, adult `Z68.38` Body mass index [BMI] 38.0-38.9, adult `Z68.39` Body mass index [BMI] 39.0-39.9, adult `Z68.41` Body mass index [BMI] 40.0-44.9, adult `Z68.42` Body mass index [BMI] 45.0-49.9, adult `Z68.43` Body mass index [BMI] 50.0-59.9, adult `Z68.44` Body mass index [BMI] 60.0-69.9, adult `Z68.45` Body mass index [BMI] 70 or greater, adult `Z68.51` Body mass index [BMI] pediatric, less than 5th percentile for age `Z68.52` Body mass index [BMI] pediatric, 5th percentile to less than 85th percentile for age `Z68.53` Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age `Z68.54` Body mass index [BMI] pediatric, 95th percentile for age to less than 120% of the 95th percentile for age `Z68.55` Body mass index [BMI] pediatric, 120% of the 95th percentile for age to less than 140% of the 95th percentile for age `Z68.56` Body mass index [BMI] pediatric, greater than or equal to 140% of the 95th percentile for age `R63` Symptoms and signs concerning food and fluid intake: distinguishes R63.6 underweight (one code) (11 codes in the category). `R63.0` Anorexia `R63.1` Polydipsia `R63.2` Polyphagia `R63.30` Feeding difficulties, unspecified `R63.31` Pediatric feeding disorder, acute `R63.32` Pediatric feeding disorder, chronic `R63.39` Other feeding difficulties `R63.4` Abnormal weight loss `R63.5` Abnormal weight gain `R63.6` Underweight `R63.8` Other symptoms and signs concerning food and fluid intake Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Anaemia measured	`who2024_anaemia@1.0` Draft · pending review Not assessable: needed to choose the population-specific thresholds: context 'pregnant' not provided; needed to choose the population-specific thresholds: context 'trimester' not provided haemoglobin 128 g/L 2026-11-12 11:00 · LM-P02-04 Window: 30 days before the check. Citation Anaemia and its severity by haemoglobin (WHO 2024) who2024_anaemia@1.0 Table 3: Adults, 15–65 years, nonpregnant women: No anaemia ≥120; Mild 110–119; Moderate 80–109; Severe <80. Adults, 15–65, years men: ≥130; 110–129; 80–109; <80 (g/L) World Health Organization, Guideline on haemoglobin cutoffs to define anaemia in individuals and populations (2024) · Executive summary: Table 2 (PDF page 12), Table 3 (PDF page 13), Table 4 (PDF page 14), Table 5 (PDF page 15) · source Contested: Cut-offs are 5th percentiles of mostly higher-income populations (WHO's own remark); the men's 130 g/L cut-off and severity percentages were debated by the guideline group; CTCAE and laboratory reference ranges use other limits; older adults (>65) are not covered. Not encoded: The elevation formula (0.0056384 x elevation + 0.0000003 x elevation²) is not used; the 500 m table rows are. The remark that tailored adjustments may be warranted above 2500 m is not encoded. Adjustment for inflammation/infection (malaria) and for genetic ancestry: WHO recommends none (normative statements 2.b and 2.c); nothing is applied. Type and cause of anaemia (iron deficiency, blood loss, haemolysis) are not assessed. Persons older than 65 years and infants under 6 months: Table 2 gives no cut-off, so they are not assessable. Exactly 20 cigarettes per day: Table 5 lists '10–19' and '>20', so 20 per day is outside the table and not assessable (source gap).	Not stated	None entered	Cannot be assessed context
Code-family reference: Anaemia Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `D64` Other anemias: distinguishes type of anaemia (sideroblastic, congenital dyserythropoietic, due to antineoplastic chemotherapy, other specified, unspecified) (8 codes in the category). `D64.0` Hereditary sideroblastic anemia `D64.1` Secondary sideroblastic anemia due to disease `D64.2` Secondary sideroblastic anemia due to drugs and toxins `D64.3` Other sideroblastic anemias `D64.4` Congenital dyserythropoietic anemia `D64.81` Anemia due to antineoplastic chemotherapy `D64.89` Other specified anemias `D64.9` Anemia, unspecified `D50` Iron deficiency anemia: distinguishes iron deficiency anaemia: secondary to chronic blood loss, sideropenic dysphagia, other, unspecified (4 codes in the category). `D50.0` Iron deficiency anemia secondary to blood loss (chronic) `D50.1` Sideropenic dysphagia `D50.8` Other iron deficiency anemias `D50.9` Iron deficiency anemia, unspecified `D62` Acute posthemorrhagic anemia: distinguishes acute posthaemorrhagic anaemia (single code) (1 codes in the category). `D62` Acute posthemorrhagic anemia Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).