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.
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 clarification request (draft) · dietitian's nutrition assessment findings · visit KE-P35
Title: Clarification request: dietitian's nutrition assessment findings
Encounter: KE-P35 Patient: P35 To: author of the draft note
From: (no named sender: sign in to send)
Date: 2026-11-13 Rule versions: front_malnutrition_us_consensus@1.0, front-engine 1.2 Check run: FRUN-00047
Clinical indicators from the health record:
- Context documented by Wren Halden, RD on 2026-11-09: "chronic illness (pancreatic adenocarcinoma on chemotherapy)" (Wren Halden, RD) [record item NA-P35-1]
- Energy intake: 50% of estimated needs for 42 days: "about 50% of estimated energy needs for 6 weeks" (Wren Halden, RD) [record item NA-P35-1]
- Weight loss: 2.8% over 1 month (65 kg on 2026-10-13 to 63.2 kg on 2026-11-12); 7.7% over 3 months (68.5 kg on 2026-08-14 to 63.2 kg on 2026-11-12); 12.2% over 6 months (72 kg on 2026-05-16 to 63.2 kg on 2026-11-12); 14% over 1 year (73.5 kg on 2025-11-12 to 63.2 kg on 2026-11-12) [record item NA-P35-1]
- Fat loss: graded mild: "mild orbital fat loss" (Wren Halden, RD) [record item NA-P35-1]
- Muscle loss: graded moderate: "moderate temporal and clavicular muscle wasting" (Wren Halden, RD) [record item NA-P35-1]
- Fluid accumulation: graded none: "no edema" (Wren Halden, RD) [record item NA-P35-1]
- Grip strength: reduced: "grip strength measurably reduced by hand dynamometer" (Wren Halden, RD) [record item NA-P35-1]
Question:
Based on your independent clinical judgement, how would you describe the clinical significance of the dietitian's nutrition assessment findings listed above?
Response options (select one or write your own):
( ) Moderate (non-severe) malnutrition in the context of chronic illness
( ) Severe malnutrition in the context of chronic illness
( ) Other (please specify): ____________
( ) Clinically unable to determine
( ) Not clinically supported
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.
Blocked: A query needs a named human sender (sign in).
Core definitions 1
Core definitions: condition families for this encounter (1)
Chronic kidney disease stage 1 · needs filtering rate 90 or above with a kidney damage marker (for example albuminuria on two tests at least 90 days apart) · record: filtering rate 60 or above; needs a kidney damage marker (no persistent albuminuria on file) · not assessable
Chronic kidney disease stage 2 · needs filtering rate 60-89 with a kidney damage marker (for example albuminuria on two tests at least 90 days apart) · record: filtering rate 60 or above; needs a kidney damage marker (no persistent albuminuria on file) · not assessable
Chronic kidney disease stage 3a · needs filtering rate 45-59 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met
Chronic kidney disease stage 3b · needs filtering rate 30-44 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met
Chronic kidney disease stage 4 · needs filtering rate 15-29 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met
Chronic kidney disease stage 5 · needs filtering rate below 15 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met
Citation
Kidney disease stage wording by filtering rate, with the albumin-to-creatinine category (options for the clinician)
front_kidney_stage_wording@1.0
In our words: Kidney disease by filtering rate: below 60 on results at least 3 months apart; or urine albumin-to-creatinine ratio 30 mg/g or higher on two tests at least 3 months apart. Stage by filtering rate: G1 90 or above; G2 60-89; G3a 45-59; G3b 30-44; G4 15-29; G5 below 15 (G1 and G2 also need a marker of kidney damage). Albumin-to-creatinine category: A1 below 30, A2 30-299, A3 300 mg/g or above. The filtering rate is estimated with the 2021 race-free creatinine equation.
Department of Veterans Affairs and Department of Defense, VA/DoD Clinical Practice Guideline for the Primary Care Management of Chronic Kidney Disease, Provider Summary (Version 5.0) (2025) ·
Sidebar 6 'Criteria for CKD' (PDF page 16; printed page 13 of 37). Do not use Sidebar 9 (a reproduced third-party figure) · source
Licence: U.S. government work (public domain); filtering-rate stage bands (90, 60, 45, 30, 15) and the G3a/G3b split: fact only citation; albumin-to-creatinine categories (A1 below 30, A2 30-299, A3 300 mg/g or above): fact only citation; 2021 creatinine equation: public domain. Source checked: opened. No endorsement by the cited bodies is implied.
To confirm with a clinician: three months is encoded as 90 days (the VA/DoD summary says 3 months or more).
Not stated
None entered
· Nothing to act on
Kidney results 200 days apart are 60 or above (filtering rate 71.8 on 2026-04-26 and 71.8 on 2026-11-12) and the note doesn't mention kidney function.
Clinician's response to the side-panel card: No response yet
Whole code category, for reference (no code is selected, ranked or suggested): Kidney disease stage (filtering rate)ⓘ Coders only
ⓘreference for coders — the clinician's documented statement governs; the software does not assign codes
N18 Chronic kidney disease (CKD) (9 codes in the category).
Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Extended capabilities (licence required before commercial use) 1
ⓘExtended capabilities: published criteria cited by title and restated in our own words, no text reproduced; a licence or permission is needed before commercial use.
Shown to coders always; on clinician screens only when the setting is on (now off).
Extended capabilities (licence required before commercial use): condition families for this encounter (1)
Record meets: Severe malnutrition in the context of chronic illness
Context documented by Wren Halden, RD on 2026-11-09: chronic illness (pancreatic adenocarcinoma on chemotherapy)(Wren Halden, RD)· NA-P35-1
Energy intake: severe level · 50% of estimated needs for 42 days: about 50% of estimated energy needs for 6 weeks(Wren Halden, RD)· NA-P35-1
Weight loss: severe level · 2.8% over 1 month (65 kg on 2026-10-13 to 63.2 kg on 2026-11-12); 7.7% over 3 months (68.5 kg on 2026-08-14 to 63.2 kg on 2026-11-12); 12.2% over 6 months (72 kg on 2026-05-16 to 63.2 kg on 2026-11-12); 14% over 1 year (73.5 kg on 2025-11-12 to 63.2 kg on 2026-11-12) · NA-P35-1
Fluid accumulation: not met · graded none: no edema(Wren Halden, RD)· NA-P35-1
Grip strength: severe level · reduced: grip strength measurably reduced by hand dynamometer(Wren Halden, RD)· NA-P35-1
Low albumin 2.9 g/dL (2026-11-09) and prealbumin 12 mg/dL (2026-11-09): not a criterion in this definition.
Options and what the record shows
Moderate (non-severe) malnutrition in the context of chronic illness · needs two or more characteristics at the moderate level or worse · record: 5 at the moderate level or worse · met
Severe malnutrition in the context of chronic illness · needs two or more characteristics at the severe level · record: 3 at the severe level · met
Citation
Adult malnutrition severity from a dietitian's nutrition assessment (US consensus characteristics, 2012)
front_malnutrition_us_consensus@1.0
In our words: Applies only when the record holds a dietitian's nutrition assessment. Six characteristics: energy intake, weight loss, fat loss, muscle loss, fluid accumulation and grip strength; at least two are required. Severe: two or more at the severe level. Moderate (non-severe): two or more at the moderate level or worse. The levels depend on the context the dietitian documents (acute illness or injury, chronic illness, or social or environmental circumstances). Example, acute illness, severe: intake at or below half of need for 5 days or more; weight loss over 2% in a week, over 5% in a month or over 7.5% in 3 months. Albumin and prealbumin are not criteria.
Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (White JV et al., J Acad Nutr Diet 2012;112:730-738), Consensus statement: characteristics recommended for the identification and documentation of adult malnutrition (2012) ·
table of clinical characteristics (cite by title; do not reproduce the table or its layout) · source
Licence: cited source; wording is ours (numbers restated, no text reproduced). Source checked: not opened. No endorsement by the cited bodies is implied.
To confirm with a clinician (dietitian reviewer): the social or environmental circumstances levels were entered from memory, not from an opened copy of the consensus.
To confirm with a clinician (dietitian reviewer): the chronic-illness severe intake level. This file has severe as 75% of need or less for 1 month or more and moderate as below 75% for 1 month or more, which differ only at exactly 75%.
To confirm with a clinician: the weight-window tolerance of plus or minus 25% of each period (a local convention for choosing the reference weight).
To confirm with a clinician: grip strength is read as reduced or not reduced; the consensus grades it against norms.
Not stated
None entered
● The record supports it; neither stated in the note nor entered
The dietitian's assessment (Wren Halden, RD, 2026-11-09) documents 3 characteristics at the severe level and 5 at the moderate level or worse (two are required); the note does not state a nutrition diagnosis.
Clinician's response to the side-panel card: No response yet · offer OF-000042