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← Back to the worklist · Whole encounter ENC-00026

Jalen Sallow: Heart failure

ENC-00026 · 63F · Hospital Medicine · admitted Mon Oct 26, 2026 10:09 AM · discharged Tue Nov 03, 2026 04:03 PM · attending Dr. Cyrus Ellingham · resident Dr. Greta Kowalczyk

Specificity gap Criteria met Open

Documented “CHF” (I50.9); criteria support the more specific Chronic diastolic (HFpEF) heart failure (I50.32).

Documented vs supported

Documented: “CHF” · I50.9 Heart failure, unspecified
Criteria support: Chronic diastolic (HFpEF) heart failure · I50.32 Chronic diastolic (congestive) heart failure
Outcome: LVEF 63%, prior heart failure, no acute indicators
Rule: Heart failure type (LVEF) and acuity v2026.11-1
Published source: Universal Definition and Classification of Heart Failure (HFSA/HFA/JHFS, 2021), as restated in Chandramouli et al., Clin Cardiol 2022 (2021), LVEF classification: HFrEF <=40%, HFmrEF 41-49%, HFpEF >=50%; HFimpEF = baseline <=40%, rise >=10 points, second LVEF >40% · source (checked 2026-11-14)
Contested: No guideline gives a numeric definition of "acute" versus "chronic" heart failure. This rule uses a LOCAL CONVENTION: at least two acute indicators (IV loop diuretic, elevated natriuretic peptide, new oxygen requirement) = acute; with a prior history of heart failure = acute on chronic; none with history = chronic; exactly one = clinical judgement.

Effect if the clinician agrees (illustrative)

Change: I50.9 -> I50.32
Secondary-diagnosis level: non-CC → CC
MS-DRG (illustrative): 193 Simple pneumonia and pleurisy with MCC → 193 Simple pneumonia and pleurisy with MCC
Relative weight: 1.3144 → 1.3144 (+0.0000)
Codes before: J18.9, E43, N18.31, I50.9, I10, E78.5, E11.9
Codes after: J18.9, E43, N18.31, I10, E78.5, E11.9, I50.32

All open gaps on this encounter together: MS-DRG 193 → 194 (RW -0.5085).

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

0.5 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
Latest LVEF within 12 months (%)	63.0	echo LVEF 63% · echo ECH-000012 · 2026-08-13 10:09
Highest BNP this stay (pg/mL)	72.0	BNP 72 pg/mL · lab LAB-000884 · 2026-10-26 11:09
Prior heart failure on the problem list / history	True	history: heart failure with preserved ejection fraction · history HX-000008

Rule trace (inputs, thresholds, outcome)

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: np_elevated	`coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false)`	bnp_max=72.0, ntprobnp_max=unknown, t.bnp=100, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=False, new_o2=False, np_elevated=False	0
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=63.0, t.pres=50, t.ref=40	diastolic
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef=63.0, lvef_prior_min=unknown, t.improved_rise=10, t.ref=40	false
derived: acuity	`case(acute_count >= 2 and hf_history, 'acute on chronic', acute_count >= 2, 'acute', acute_count == 0 and hf_history, 'chronic', null)`	acute_count=0, hf_history=True	chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	acuity=chronic, hf_type=diastolic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	acuity=chronic, hf_type=diastolic	false
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	acuity=chronic, hf_type=diastolic	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2003); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: cardiac documentation
Encounter: ENC-00026   Patient: Jalen Sallow   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "CHF" [Progress note DOC-000086]
- echo LVEF 63% (2026-08-13 10:09) [echo ECH-000012]
- BNP 72 pg/mL (2026-10-26 11:09) [lab LAB-000884]
- history: heart failure with preserved ejection fraction [history HX-000008]

Question:
Based on your clinical judgement and the indicators above, can the type and acuity of the heart failure being treated be further specified?

Response options (select one or write your own):
( ) Chronic diastolic heart failure (HFpEF)
( ) Acute on chronic diastolic heart failure (HFpEF)
( ) 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

Malnutrition · Clinical validation gap Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2003	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00026, ENC-00026.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 0aa875a3b05b
1177	2026-11-14T19:24:28	system:llm system	`llm.call`	ENC-00026, ENC-00026.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 43a7e19b0159
435	2026-11-14T18:29:03	system:llm system	`llm.call`	ENC-00026, ENC-00026.heart_failure	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 97eeabcf72dd output 752ce96b1cd3 entry 6bc390b0cdc6