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P40 KE-P40 · 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.

Note: unsigned draft

Side-panel conditions check FRUN-00048 · front-engine 1.2 · replay 7e29df74215f14d1…

Library check LRUN-00048 · library_default_set@1.1 · library-engine 1.1 · replay b03be1616c5d9426… · Data (JSON)

Core definitions 1

Core definitions: condition families for this encounter (1)
Condition familyWhat the record supportsWhat the note states Visit diagnosis entriesAssessment
Kidney disease stage (filtering rate)
measured · side-panel condition

front_kidney_stage_wording@1.0 Draft · pending review

No wording's requirement is met by the record

    Options and what the record shows
    • 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.

    Decreased eGFR <60 mL/min/1.73 m2 (GFR categories G3a-G5) for ≥3 months

    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 85.0 on 2026-04-26 and 85.0 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).

    • N18.1 Chronic kidney disease, stage 1
    • N18.2 Chronic kidney disease, stage 2 (mild)
    • N18.30 Chronic kidney disease, stage 3 unspecified
    • N18.31 Chronic kidney disease, stage 3a
    • N18.32 Chronic kidney disease, stage 3b
    • N18.4 Chronic kidney disease, stage 4 (severe)
    • N18.5 Chronic kidney disease, stage 5
    • N18.6 End stage renal disease
    • N18.9 Chronic kidney disease, unspecified

    Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).

    Extended capabilities (licence required before commercial use) 0

    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).

    Nothing in this section for this encounter.