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-00054
Elena Okafor: Malnutrition
ENC-00054 · 49M · Hospital Medicine · admitted Mon Nov 09, 2026 10:24 AM · in hospital · attending Dr. Wes Merriweather · resident Dr. Greta Kowalczyk
Specificity gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “malnourished” (E46); criteria support the more specific Severe protein-calorie malnutrition (acute illness context) (E43).
Documented vs supported
- Documented
- “malnourished” · E46 Unspecified protein-calorie malnutrition
- Criteria support
- Severe protein-calorie malnutrition (acute illness context) · E43 Unspecified severe protein-calorie malnutrition
- Outcome
- 5 severe characteristics (acute illness context)
- 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.
Effect if the clinician agrees (illustrative)
- Change
- E46 -> E43
- Secondary-diagnosis level
- CC → MCC
- MS-DRG (illustrative)
- 871 Septicemia or severe sepsis without MV >96 hours with MCC → 871 Septicemia or severe sepsis without MV >96 hours with MCC
- Relative weight
- 1.9425 → 1.9425 (+0.0000)
- Codes before
- A41.9, J18.9, E46, N18.9
- Codes after
- A41.9, J18.9, N18.9, E43
All open gaps on this encounter together: MS-DRG 871 → 193 (RW -0.6281).
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.
| Input | Value | Source |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | acute |
“Context: acute illness”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Elena Okafor MRN: MRN76087701
Context: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subc … |
| Energy intake as % of estimated need | 40.0 |
“estimated energy intake 40% of needs for 10 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Elena Okafor MRN: MRN76087701
Context: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat … |
| Duration of reduced intake (days) | 10.0 |
“estimated energy intake 40% of needs for 10 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Elena Okafor MRN: MRN76087701
Context: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat … |
| Weight loss (%) | 5.6 |
“5.6% weight loss over 30 days”
Show the quote in the note… egistered Dietitian)
Patient: Elena Okafor MRN: MRN76087701
Context: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Re … |
| Period of the weight loss (days) | 30.0 |
“5.6% weight loss over 30 days”
Show the quote in the note… egistered Dietitian)
Patient: Elena Okafor MRN: MRN76087701
Context: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Re … |
| Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe) | 2 |
“moderate loss of subcutaneous fat”
Show the quote in the note… ontext: acute illness
Intake: estimated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Recommendations: high-protein oral supplement; calorie counts; weekly … |
| Muscle mass loss (0-3) | 2 |
“moderate muscle wasting”
Show the quote in the note… ated energy intake 40% of needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Recommendations: high-protein oral supplement; calorie counts; weekly weights. |
| Fluid accumulation (0-3) | 0 |
“no fluid accumulation”
Show the quote in the note… needs for 10 days.
Weight history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Recommendations: high-protein oral supplement; calorie counts; weekly weights. |
| Grip strength measurably reduced | True |
“Grip strength: reduced”
Show the quote in the note… ght history: 5.6% weight loss over 30 days.
Nutrition-focused physical exam: moderate loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Grip strength: reduced per dynamometry.
Recommendations: high-protein oral supplement; calorie counts; weekly weights. |
Rule trace (inputs, thresholds, outcome)
| 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=10.0, intake_pct=40.0, t.a_sev_intake_days=5, t.a_sev_intake_pct=50 | true |
| derived: a_mod_intake | intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days |
intake_days=10.0, intake_pct=40.0, 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=30.0, wt_loss_pct=5.6 | true |
| 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=30.0, wt_loss_pct=5.6 | true |
| derived: c_sev_intake | intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=10.0, intake_pct=40.0, 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=10.0, intake_pct=40.0, 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=30.0, wt_loss_pct=5.6 | true |
| 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=30.0, wt_loss_pct=5.6 | true |
| derived: n_assessed | known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) |
fat_loss=2, fluid=0, grip_reduced=True, intake_pct=40.0, muscle_loss=2, wt_loss_pct=5.6 | 6 |
| 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=True, a_sev_wt=True, c_sev_intake=False, c_sev_wt=True, fat_loss=2, fluid=0, grip_reduced=True, muscle_loss=2, nutr_context=acute | 5 |
| 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=True, a_sev_intake=True, a_sev_wt=True, c_mod_intake=False, c_mod_wt=True, c_sev_intake=False, c_sev_wt=True, fat_loss=2, fluid=0, grip_reduced=True, muscle_loss=2, nutr_context=acute | 5 |
| outcome: severe | n_severe >= 2 |
n_severe=5 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2067); 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-00054 Patient: Elena Okafor To: Dr. Wes Merriweather Clinical indicators from the health record: - Documented in the record: "malnourished" [Progress note DOC-000190] - "Context: acute illness" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 4] - "estimated energy intake 40% of needs for 10 days" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 5] - "estimated energy intake 40% of needs for 10 days" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 5] - "5.6% weight loss over 30 days" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 6] - "5.6% weight loss over 30 days" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 6] - "moderate loss of subcutaneous fat" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 7] - "moderate muscle wasting" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 7] - "no fluid accumulation" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 7] - "Grip strength: reduced" (2026-11-10 14:24) [Nutrition assessment DOC-000188, p. 1, line 8] Question: The dietitian assessment above is documented in this encounter. Based on your clinical judgement, can a related nutritional diagnosis, including severity, be documented? Response options (select one or write your own): ( ) Severe protein-calorie malnutrition ( ) Moderate protein-calorie malnutrition ( ) 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
- Chronic kidney disease · Specificity gap Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
- Sepsis · Clinical validation gap Documented “sepsis” (A41.9) but the criteria are not met: Neither definition met: 0 SIRS criteria, SOFA change 0.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2067 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00054, ENC-00054.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry 22ac43f64432 |
| 1241 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00054, ENC-00054.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry dec4c3b0e68f |
| 499 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00054, ENC-00054.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry ad7c05296658 |