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.

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Vera Quillan: Acute blood loss anaemia

ENC-00048 · 47M · Hospital Medicine · admitted Wed Nov 11, 2026 10:35 PM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Elena Nakashima

Specificity gap Criteria met Open In hospital: concurrent review Resident note awaiting attending cosign

Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).

Documented vs supported

Documented: “anemia” · D64.9 Anemia, unspecified
Criteria support: Acute blood loss anemia · D62 Acute posthemorrhagic anemia
Outcome: Haemoglobin fell 2.7 g/dL to 10.4 with 2 unit(s) transfused and a documented bleeding source
Rule: Acute blood loss anaemia v2026.11-1
Published source: WHO guideline on haemoglobin cutoffs to define anaemia in individuals and populations (2024), Adult cut-offs: men <13 g/dL, non-pregnant women <12 g/dL (unchanged from 2011) · source (checked 2026-11-14)
Contested: There is no published clinical definition of "acute blood loss anaemia". This rule is a LOCAL CONVENTION: WHO anaemia threshold at the nadir, a documented bleeding source, and an acute fall of >=2 g/dL OR >=2 units transfused (borrowed from the ISTH major-bleeding definition, which secondary restatements word inconsistently as AND/OR).

Effect if the clinician agrees (illustrative)

Change: D64.9 -> D62
Secondary-diagnosis level: non-CC → CC
MS-DRG (illustrative): 690 Kidney and urinary tract infections without MCC → 690 Kidney and urinary tract infections without MCC
Relative weight: 0.8095 → 0.8095 (+0.0000)
Codes before: N39.0, E46, D64.9, E11.9, E78.5, K21.9
Codes after: N39.0, E46, E11.9, E78.5, K21.9, D62

All open gaps on this encounter together: MS-DRG 690 → 690 (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

0.5 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
Sex	M	sex M · encounter ENC-00048
First haemoglobin this stay (g/dL)	13.13	hemoglobin 13.13 g/dL (first) · lab LAB-001651 · 2026-11-11 23:35
Lowest haemoglobin this stay (g/dL)	10.4	hemoglobin 10.4 g/dL (lowest) · lab LAB-001653 · 2026-11-13 05:00
Highest value before the nadir minus the nadir (g/dL) highest value before the nadir minus the nadir	2.7	hemoglobin 13.13 · lab LAB-001651 · 2026-11-11 23:35 hemoglobin 10.4 · lab LAB-001653 · 2026-11-13 05:00
Red cell units transfused	2	transfuse 2 unit(s) PRBC · order ORD-000040 · 2026-11-12 09:00
A bleeding source quoted from a note, or a bleeding principal diagnosis	True	“black tarry stools” · History and physical DOC-000167, p. 1, line 5 · quoted span verified Show the quote in the note … : 47-year-old man admitted with urinary tract infection. Urinalysis with pyuria; treated for acute pyelonephritis with cefepime. Hospital course complicated by black tarry stools. Past medical history: type 2 diabetes, hyperlipidemia, GERD. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, no distress. …

Rule trace (inputs, thresholds, outcome)

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	hgb_nadir=10.4, sex=M, t.hb_f=12, t.hb_m=13	true
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=2.7, prbc_units=2, t.drop_major=2.0, t.prbc_major=2	true
outcome: met	`bleeding_documented and anaemic and acute_fall`	acute_fall=True, anaemic=True, bleeding_documented=True	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2055); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: hematology documentation
Encounter: ENC-00048   Patient: Vera Quillan   To: Dr. Rosalind Quillan

Clinical indicators from the health record:
- Documented in the record: "anemia" [Progress note DOC-000168]
- sex M [encounter ENC-00048]
- hemoglobin 13.13 g/dL (first) (2026-11-11 23:35) [lab LAB-001651]
- hemoglobin 10.4 g/dL (lowest) (2026-11-13 05:00) [lab LAB-001653]
- transfuse 2 unit(s) PRBC (2026-11-12 09:00) [order ORD-000040]
- "black tarry stools" (2026-11-12 01:35) [History and physical DOC-000167, p. 1, line 5]

Question:
Based on your clinical judgement and the indicators above, can the type or cause of the condition being monitored and treated be further specified?

Response options (select one or write your own):
( ) Acute blood loss anemia
( ) Anemia, type not further specified
( ) 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 · Specificity gap Documented “malnutrition” (E46); criteria support the more specific 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
2055	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00048, ENC-00048.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 6be16a7af78b output bfa18fc1e32e entry e1ff00a9b116
1229	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00048, ENC-00048.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 6be16a7af78b output bfa18fc1e32e entry 8ab9630df327
487	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00048, ENC-00048.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 6be16a7af78b output bfa18fc1e32e entry eb0a976f18d1