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-00028
Greta Nakashima: Sepsis
ENC-00028 · 62M · Hospital Medicine · admitted Mon Nov 02, 2026 04:51 PM · discharged Mon Nov 09, 2026 03:10 PM · attending Dr. Rosalind Quillan · resident Dr. Keira Upfield
Clinical validation gap Criteria not met Open
Contested definitions (Sepsis-2 vs Sepsis-3)
Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.
Documented vs supported
- Documented
- “sepsis” · A41.9 Sepsis, unspecified organism
- Criteria support
- criteria not met
- Outcome
- Neither definition met: 0 SIRS criteria, SOFA change 0
- Rule
- Sepsis (clinical validation; Sepsis-3 and Sepsis-2 shown side by side) v2026.11-1
- Published source
- The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), Singer et al., JAMA 2016;315:801-810 (2016), Boxes 3-4: sepsis = infection + acute change in total SOFA >=2 (baseline 0 unless known); septic shock = vasopressors for MAP >=65 and lactate >2 mmol/L despite adequate volume · source (checked 2026-11-14)
- Contested
- CONTESTED DEFINITIONS. Sepsis-3 (organ dysfunction, SOFA) is the current consensus definition; Sepsis-2 (SIRS) is still used by the CMS SEP-1 quality measure and by many payers' clinical-validation policies. When the two disagree this rule never concludes: it returns "clinical judgement required (definition-dependent)". ICD-10-CM guideline I.A.19: code assignment is based on the provider's statement, not on clinical criteria; clinical validation is a separate process. The rule validates documented sepsis only and never prompts for an undocumented sepsis diagnosis.
Effect if the clinician agrees (illustrative)
- Change
- principal A41.9 removed; J18.9 becomes principal
- Secondary-diagnosis level
- principal → removed
- MS-DRG (illustrative)
- 871 Septicemia or severe sepsis without MV >96 hours with MCC → 193 Simple pneumonia and pleurisy with MCC
- Relative weight
- 1.9425 → 1.3144 (-0.6281)
- Codes before
- A41.9, J18.9, E43, N17.9, E11.9
- Codes after
- J18.9, E43, N17.9, E11.9
All open gaps on this encounter together: MS-DRG 871 → 194 (RW -1.1366).
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
-1.0 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.
| Input | Value | Source |
|---|---|---|
| Infection quoted from a note or an infection principal diagnosis | True |
“multifocal pneumonia”
Show the quote in the note… 6-11-02 16:51
Service: Hospital Medicine Attending: Dr. Rosalind Quillan
History of present illness: 62-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation …
principal diagnosis A41.9
|
| Highest temperature, first 48 h (C) | 37.7 |
temperature 37.7 °C
|
| Lowest temperature, first 48 h (C) | 37.2 |
temperature 37.2 °C
|
| Highest heart rate, first 48 h | 86.0 |
heart rate 86/min
|
| Highest respiratory rate, first 48 h | 20.0 |
respiratory rate 20/min
|
| Highest WBC, first 48 h (x10^3/uL) | 9.07 |
WBC 9.07 x10^3/uL
|
| Lowest WBC, first 48 h (x10^3/uL) | 7.66 |
WBC 7.66 x10^3/uL
|
| Lowest platelets, first 48 h (x10^3/uL) | 200.0 |
platelets 200 x10^3/uL
|
| Highest bilirubin, first 48 h (mg/dL) | 0.8 |
bilirubin 0.8 mg/dL
|
| Lowest mean arterial pressure, first 48 h (mmHg) | 79.0 |
MAP 79 mmHg
|
| Highest norepinephrine-equivalent dose, first 48 h (mcg/kg/min) no vasopressor in the first 48 hours |
0.0 | derived (no vasopressor in the first 48 hours) |
| Lowest Glasgow Coma Scale, first 48 h | 15.0 |
GCS 15
|
| Highest creatinine, first 48 h (mg/dL) | 1.59 |
creatinine 1.59 mg/dL
|
| Baseline creatinine (mg/dL), for the baseline renal SOFA score most recent pre-admission value within 365 days |
1.52 |
creatinine 1.52 mg/dL (pre-admission)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: sirs_temp | coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false) |
t.t_hi=38, t.t_lo=36, temp_max_48h=37.7, temp_min_48h=37.2 | false |
| derived: sirs_hr | coalesce(hr_max_48h > t.hr, false) |
hr_max_48h=86.0, t.hr=90 | false |
| derived: sirs_rr | coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false) |
paco2_min_48h=unknown, rr_max_48h=20.0, t.paco2=32, t.rr=20 | false |
| derived: sirs_wbc | coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false) |
bands_max_48h=unknown, t.bands=10, t.wbc_hi=12, t.wbc_lo=4, wbc_max_48h=9.07, wbc_min_48h=7.66 | false |
| derived: sirs_count | count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc) |
sirs_hr=False, sirs_rr=False, sirs_temp=False, sirs_wbc=False | 0 |
| derived: sofa_resp | coalesce(case(pf_min_48h < 100 and adv_resp_support, 4, pf_min_48h < 200 and adv_resp_support, 3, pf_min_48h < 300, 2, pf_min_48h < 400, 1, 0), 0) |
adv_resp_support=False, pf_min_48h=unknown | 0 |
| derived: sofa_coag | coalesce(case(platelets_min_48h < 20, 4, platelets_min_48h < 50, 3, platelets_min_48h < 100, 2, platelets_min_48h < 150, 1, 0), 0) |
platelets_min_48h=200.0 | 0 |
| derived: sofa_liver | coalesce(case(bili_max_48h >= 12, 4, bili_max_48h >= 6, 3, bili_max_48h >= 2, 2, bili_max_48h >= 1.2, 1, 0), 0) |
bili_max_48h=0.8 | 0 |
| derived: sofa_cardio | coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0) |
map_min_48h=79.0, norepi_max_48h=0.0 | 0 |
| derived: sofa_cns | coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0) |
gcs_min_48h=15.0 | 0 |
| derived: sofa_renal | coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0) |
creat_max_48h=1.59 | 1 |
| derived: sofa_renal_baseline | coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0) |
creat_baseline=1.52 | 1 |
| derived: sofa_delta | sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline |
sofa_cardio=0, sofa_cns=0, sofa_coag=0, sofa_liver=0, sofa_renal=1, sofa_renal_baseline=1, sofa_resp=0 | 0 |
| derived: sepsis3 | infection_documented and sofa_delta >= t.sofa_delta |
infection_documented=True, sofa_delta=0, t.sofa_delta=2 | false |
| derived: sepsis2 | infection_documented and sirs_count >= t.sirs_min |
infection_documented=True, sirs_count=0, t.sirs_min=2 | false |
| derived: shock | sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false) |
lactate_max_48h=unknown, norepi_max_48h=0.0, sepsis3=False, t.lactate=2 | false |
| outcome: no_infection | not infection_documented |
infection_documented=True | false |
| outcome: septic_shock | shock |
shock=False | false |
| outcome: both | sepsis3 and sepsis2 |
sepsis2=False, sepsis3=False | false |
| outcome: sepsis3_only | sepsis3 |
sepsis3=False | false |
| outcome: definitions_disagree | sepsis2 |
sepsis2=False | false |
| outcome: neither | true |
— | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2011); clinical indicators and answer options assembled by code from the rule and the record.
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DOCUMENTATION QUERY (draft) Title: Clarification request: infection-related documentation Encounter: ENC-00028 Patient: Greta Nakashima To: Dr. Rosalind Quillan Clinical indicators from the health record: - Documented in the record: "sepsis" [History and physical DOC-000093] - "multifocal pneumonia" (2026-11-02 19:51) [History and physical DOC-000093, p. 1, line 5] - principal diagnosis A41.9 [encounter ENC-00028] - temperature 37.7 °C (2026-11-04 09:11) [vital VIT-002804] - temperature 37.2 °C (2026-11-04 01:11) [vital VIT-002800] - heart rate 86/min (2026-11-03 17:11) [vital VIT-002797] - respiratory rate 20/min (2026-11-03 09:11) [vital VIT-002747] - WBC 9.07 x10^3/uL (2026-11-03 05:00) [lab LAB-000978] - WBC 7.66 x10^3/uL (2026-11-02 17:51) [lab LAB-000976] - platelets 200 x10^3/uL (2026-11-02 17:51) [lab LAB-000977] - bilirubin 0.8 mg/dL (2026-11-02 17:51) [lab LAB-000992] - MAP 79 mmHg (2026-11-03 17:11) [vital VIT-002798] - GCS 15 (2026-11-02 17:11) [vital VIT-002787] - creatinine 1.59 mg/dL (2026-11-03 05:00) [lab LAB-000953] - creatinine 1.52 mg/dL (pre-admission) (2026-09-05 10:05) [lab LAB-000951] Question: The indicators above are documented in this encounter. Could you clarify the status of the documented infection-related diagnosis? Response options (select one or write your own): ( ) Sepsis: confirmed (please document the supporting clinical information) ( ) Sepsis: 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.
Other findings on this encounter
- Acute kidney injury · Clinical validation gap Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
- Chronic kidney disease · Specificity gap Criteria support Chronic kidney disease stage 3a (N18.31); no corresponding diagnosis is documented.
- 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
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2011 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00028, ENC-00028.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry fae4790704b8 |
| 1185 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00028, ENC-00028.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 03c009dcfb38 |
| 443 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00028, ENC-00028.sepsis | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 78551a867831 |