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P22 KE-P22 · 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-00022 · library_default_set@1.0 · library-engine 1.0 · replay 1996f5ba5c7affd9… · Data (JSON)

Condition families for this encounter (2)
Condition familyWhat the record supportsWhat the note states Visit diagnosis entriesAssessment
Anaemia
measured

who2024_anaemia@1.0 Draft · pending review

Moderate anaemia

  • haemoglobin 104 g/L 2026-11-10 09:05 · LM-P22-01

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

The record supports it; neither stated in the note nor entered

Draft a query

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).

Hypertension
measured

nhlbi_bp_categories@1.0 Draft · pending review

Not assessable: no reading with all of bp_systolic_office, bp_diastolic_office recorded at the same time; no usable bp_diastolic_office measurement; no usable bp_systolic_office measurement

Window: 365 days before the check.

Another published definition (esc2024_office_bp@1.0) gives: not assessable.

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).

Hypertension

None entered

Cannot be assessed

no_value

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).