Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

← Back to the worklist · Whole encounter ENC-00003

Camila Lindqvist: Malnutrition

ENC-00003 · 74F · Cardiology · admitted Thu Oct 29, 2026 08:28 PM · discharged Tue Nov 03, 2026 01:43 PM · attending Dr. Kenji Stavros

Clinical judgement required Clinical judgement required Open

Clinical judgement required: Only one consensus characteristic documented; two are required.

Documented vs supported

Documented: “malnutrition” · E46 Unspecified protein-calorie malnutrition
Criteria support: no conclusion: clinical judgement required
Outcome: Only one consensus characteristic documented; two are required
Rule: Malnutrition severity (ASPEN/Academy 2012 consensus characteristics) v2026.11-1
Published source: Consensus statement: Academy of Nutrition and Dietetics and ASPEN: characteristics recommended for the identification and documentation of adult malnutrition (White JV et al., J Acad Nutr Diet 2012;112:730-738) (2012), Table: clinical characteristics; at least two of six characteristics; acute illness and chronic illness contexts · source (checked 2026-11-14)
Contested: GLIM (2019) is an alternative, internationally endorsed framework with different thresholds; an organization must choose one per policy. This rule encodes ASPEN/Academy 2012 and lists GLIM as the alternative.

Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.

Effect if the clinician agrees (illustrative)

Change: no projected change (clinician judgement)
Secondary-diagnosis level: CC → —
MS-DRG (illustrative): 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
Relative weight: 0.8490 → 0.8490 (+0.0000)
Codes before: I50.9, E46, N28.9, I10, K21.9
Codes after: I50.9, E46, N28.9, I10, K21.9

All open gaps on this encounter together: MS-DRG 292 → 292 (RW +0.0000). The grouping does not change; the record becomes accurate.

CC/MCC status, CC exclusions (subset) and relative weights from the public CMS FY2026 IPPS final rule tables (5, 6I, 6J, 6K). This is not a grouper and not a payment estimate. Queries never mention any of this.

Severity documentation index change SIMULATED

0.0 points

SIMULATED: Illustrative severity weights (MCC = 1.0, CC = 0.5, non-CC = 0) summed over secondary diagnoses; not a validated risk-adjustment model and not a measured effect.

Evidence

Structured values are read by code from the cited rows. Note facts are shown only when the model's quote was found verbatim in the note.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Context from the dietitian assessment ("acute" or "chronic" illness)	acute	“Context: acute illness” · Nutrition assessment DOC-000008, p. 1, line 4 · quoted span verified Show the quote in the note NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of sub …
Energy intake as % of estimated need	60.0	“estimated energy intake 60% of needs for 11 days” · Nutrition assessment DOC-000008, p. 1, line 5 · quoted span verified Show the quote in the note NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
Duration of reduced intake (days)	11.0	“estimated energy intake 60% of needs for 11 days” · Nutrition assessment DOC-000008, p. 1, line 5 · quoted span verified Show the quote in the note NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe)	0	“no loss of subcutaneous fat” · Nutrition assessment DOC-000008, p. 1, line 7 · quoted span verified Show the quote in the note … acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.
Muscle mass loss (0-3)	0	“no muscle wasting” · Nutrition assessment DOC-000008, p. 1, line 7 · quoted span verified Show the quote in the note … ted energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.
Fluid accumulation (0-3)	0	“no fluid accumulation” · Nutrition assessment DOC-000008, p. 1, line 7 · quoted span verified Show the quote in the note … 0% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.

Rule trace (inputs, thresholds, outcome)

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_days=11.0, intake_pct=60.0, t.a_sev_intake_days=5, t.a_sev_intake_pct=50	false
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_days=11.0, intake_pct=60.0, t.a_mod_intake_days=7, t.a_mod_intake_pct=75	true
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_days=11.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_days=11.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75	false
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	fat_loss=0, fluid=0, grip_reduced=unknown, intake_pct=60.0, muscle_loss=0, wt_loss_pct=unknown	4
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	a_sev_intake=False, a_sev_wt=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute	0
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	a_mod_intake=True, a_mod_wt=unknown, a_sev_intake=False, a_sev_wt=unknown, c_mod_intake=False, c_mod_wt=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute	1
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=1	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=1	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #1964); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: nutrition documentation
Encounter: ENC-00003   Patient: Camila Lindqvist   To: Dr. Kenji Stavros

Clinical indicators from the health record:
- Documented in the record: "malnutrition" [Progress note DOC-000010]
- "Context: acute illness" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 4]
- "estimated energy intake 60% of needs for 11 days" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 5]
- "estimated energy intake 60% of needs for 11 days" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 5]
- "no loss of subcutaneous fat" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 7]
- "no muscle wasting" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 7]
- "no fluid accumulation" (2026-10-30 23:28) [Nutrition assessment DOC-000008, p. 1, line 7]

Question:
Could you review the nutrition assessment above and clarify any related diagnosis, if clinically appropriate?

Response options (select one or write your own):
( ) Other (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.

Other findings on this encounter

Acute kidney injury · Specificity gap Documented “renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).
Heart failure · Clinical judgement required Clinical judgement required: LVEF 48% (HFmrEF, 41-49%); the type wording and its coding convention need the clinician.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
1964	2026-11-14T20:57:22	system:llm system	`llm.call`	ENC-00003, ENC-00003.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry a518b2e28cd4
1138	2026-11-14T19:24:27	system:llm system	`llm.call`	ENC-00003, ENC-00003.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry ad6093bb0182
396	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00003, ENC-00003.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry 0085411b6295