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)

Draft query: Hyponatraemia

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-P28 · sodium
Title: Clarification request: sodium results
Encounter: KE-P28   Patient: P28   To: author of the draft note
From: (no named sender: sign in to send)
Date: 2026-11-13   Rule versions: ese2014_hyponatraemia@1.0, library_default_set@1.0   Check run: LRUN-00028

Clinical indicators from the health record:
- Visit diagnosis list entry: "Hypo-osmolality and hyponatremia" [visit diagnosis list LD-P28-1]
- Sodium 139 mmol/L (2026-11-11 09:05) [measurement LM-P28-02]

Question:
Based on your independent clinical judgement, can the documentation of this condition be clarified in light of the sodium results listed above?

Response options (select one or write your own):
( ) Hypo-osmolality and hyponatremia: confirmed (please document the supporting clinical information)
( ) Hypo-osmolality and hyponatremia: ruled out
( ) Other explanation of the clinical findings (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
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).