P07 KE-P07 · 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-00007 · library_default_set@1.0 · library-engine 1.0 · replay 7e6a5c327d655f67… · Data (JSON)

Condition families for this encounter (1)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Chronic obstructive pulmonary disease (airflow component) judgement tier	`gold2026_copd_airflow@1.0` Draft · pending review GOLD 2 (moderate): 50% ≤ FEV1 <80% predicted fev1 fvc ratio post bd 0.58 ratio 2026-09-11 10:00 · LM-P07-01 fev1 pct predicted post bd 62 % 2026-09-11 10:00 · LM-P07-02 Window: 1095 days before the check. Citation COPD airflow obstruction grade by post-bronchodilator spirometry (GOLD 2026) gold2026_copd_airflow@1.0 In patients with COPD (FEV1/FVC < 0.7): GOLD 1: Mild FEV1 ≥ 80% predicted; GOLD 2: Moderate 50% ≤ FEV1 < 80% predicted; GOLD 3: Severe 30% ≤ FEV1 < 50% predicted; GOLD 4: Very Severe FEV1 < 30% predicted Global Initiative for Chronic Obstructive Lung Disease (GOLD), Global Strategy for Prevention, Diagnosis and Management of COPD: 2026 Report — Pocket Guide (2026) · Figure 2.10 (PDF page 20); key points (PDF page 11) · source Contested: The fixed ratio 0.7 is contested against the lower limit of normal (z-score) approach used by ATS/ERS interpretation standards (not opened); the fixed ratio over-diagnoses in older and under-diagnoses in younger adults. Not encoded: COPD also needs the appropriate clinical context (symptoms, exposures); the grade describes airflow obstruction only and never says COPD is present. Symptom and exacerbation assessment (GOLD ABE groups, mMRC, CAT) is not encoded. Pre-COPD and PRISm are not encoded. Whether the test was post-bronchodilator is asserted by the sender through the analyte name.	COPD COPD	`J44.9` Chronic obstructive pulmonary disease, unspecified (visit diagnosis list (synthetic))	Cannot be assessed judgement tier: the record shows these values; the condition needs clinical judgement
Code-family reference: Chronic obstructive pulmonary disease (airflow component) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `J44` Other chronic obstructive pulmonary disease: distinguishes COPD with acute lower respiratory infection, with acute exacerbation, bronchiolitis obliterans, other specified, unspecified; the code set does not distinguish GOLD grades (5 codes in the category). `J44.0` Chronic obstructive pulmonary disease with (acute) lower respiratory infection `J44.1` Chronic obstructive pulmonary disease with (acute) exacerbation `J44.81` Bronchiolitis obliterans and bronchiolitis obliterans syndrome `J44.89` Other specified chronic obstructive pulmonary disease `J44.9` Chronic obstructive pulmonary disease, unspecified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).