P28 KE-P28 · 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-00028 · library_default_set@1.0 · library-engine 1.0 · replay 6eca4102460907ed… · Data (JSON)

Condition families for this encounter (2)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Hyponatraemia measured	`ese2014_hyponatraemia@1.0` Draft · pending review Criteria not met: 135 mmol/L or above sodium serum 139 mmol/L 2026-11-11 09:05 · LM-P28-02 Window: 14 days before the check. Citation Hyponatraemia, presence only (ESE/ESICM/ERA-EDTA 2014) ese2014_hyponatraemia@1.0 Hyponatraemia, defined as a serum sodium concentration <135 mmol/l European Society of Intensive Care Medicine, European Society of Endocrinology and European Renal Association – European Dialysis and Transplant Association (ERBP), Clinical practice guideline on diagnosis and treatment of hyponatraemia (2014) · Abstract · source Not encoded: The guideline's severity bands (mild, moderate, profound) and its acute (<48 h) versus chronic classification: the full text could not be opened (publisher pages refused or errored), so they are not encoded. See the catalogue entry ese2014_hyponatraemia_severity. Correction for hyperglycaemia, measurement artefacts (pseudohyponatraemia) and symptoms are not assessed.	Not stated	`E87.1` Hypo-osmolality and hyponatremia (visit diagnosis list (synthetic))	Entered or stated without support in the record Draft a query
Code-family reference: Hyponatraemia Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E87` Other disorders of fluid, electrolyte and acid-base balance: distinguishes E87.1 hypo-osmolality and hyponatremia (one code; no severity axis) (14 codes in the category). `E87.0` Hyperosmolality and hypernatremia `E87.1` Hypo-osmolality and hyponatremia `E87.20` Acidosis, unspecified `E87.21` Acute metabolic acidosis `E87.22` Chronic metabolic acidosis `E87.29` Other acidosis `E87.3` Alkalosis `E87.4` Mixed disorder of acid-base balance `E87.5` Hyperkalemia `E87.6` Hypokalemia `E87.70` Fluid overload, unspecified `E87.71` Transfusion associated circulatory overload `E87.79` Other fluid overload `E87.8` Other disorders of electrolyte and fluid balance, not elsewhere classified 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).