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: Sepsis

ENC-00054 · 49M · Hospital Medicine · admitted Mon Nov 09, 2026 10:24 AM · in hospital · attending Dr. Wes Merriweather · resident Dr. Greta Kowalczyk

Clinical validation gap Criteria not met Open In hospital: concurrent review Resident note awaiting attending cosign 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 → 194 Simple pneumonia and pleurisy with CC
Relative weight: 1.9425 → 0.8059 (-1.1366)
Codes before: A41.9, J18.9, E46, N18.9
Codes after: J18.9, E46, N18.9

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

-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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Infection quoted from a note or an infection principal diagnosis	True	“multifocal pneumonia” · History and physical DOC-000189, p. 1, line 5 · quoted span verified Show the quote in the note … 6-11-09 10:24 Service: Hospital Medicine Attending: Dr. Wes Merriweather History of present illness: 49-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: scattered crackles at … principal diagnosis A41.9 · encounter ENC-00054
Highest temperature, first 48 h (C)	37.6	temperature 37.6 °C · vital VIT-005259 · 2026-11-09 10:44
Lowest temperature, first 48 h (C)	36.7	temperature 36.7 °C · vital VIT-005263 · 2026-11-09 18:44
Highest heart rate, first 48 h	86.0	heart rate 86/min · vital VIT-005268 · 2026-11-10 02:44
Highest respiratory rate, first 48 h	19.0	respiratory rate 19/min · vital VIT-005242 · 2026-11-10 18:44
Highest WBC, first 48 h (x10^3/uL)	8.73	WBC 8.73 x10^3/uL · lab LAB-001842 · 2026-11-09 11:24
Lowest WBC, first 48 h (x10^3/uL)	7.73	WBC 7.73 x10^3/uL · lab LAB-001844 · 2026-11-10 05:00
Lowest platelets, first 48 h (x10^3/uL)	214.0	platelets 214 x10^3/uL · lab LAB-001845 · 2026-11-10 05:00
Highest bilirubin, first 48 h (mg/dL)	0.51	bilirubin 0.51 mg/dL · lab LAB-001852 · 2026-11-09 11:24
Lowest mean arterial pressure, first 48 h (mmHg)	74.0	MAP 74 mmHg · vital VIT-005277 · 2026-11-10 18:44
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 · vital VIT-005262 · 2026-11-09 10:44
Highest creatinine, first 48 h (mg/dL)	3.43	creatinine 3.43 mg/dL · lab LAB-001829 · 2026-11-11 05:00
Baseline creatinine (mg/dL), for the baseline renal SOFA score most recent pre-admission value within 365 days	3.26	creatinine 3.26 mg/dL (pre-admission) · lab LAB-001826 · 2026-07-24 10:05

Rule trace (inputs, thresholds, outcome)

Rule trace (rule sepsis v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=37.6, temp_min_48h=36.7	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=19.0, 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=8.73, wbc_min_48h=7.73	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=214.0	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=0.51	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=74.0, 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=3.43	2
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=3.26	2
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=2, sofa_renal_baseline=2, 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 #2068); 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-00054   Patient: Elena Okafor   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "sepsis" [History and physical DOC-000189]
- "multifocal pneumonia" (2026-11-09 13:24) [History and physical DOC-000189, p. 1, line 5]
- principal diagnosis A41.9 [encounter ENC-00054]
- temperature 37.6 °C (2026-11-09 10:44) [vital VIT-005259]
- temperature 36.7 °C (2026-11-09 18:44) [vital VIT-005263]
- heart rate 86/min (2026-11-10 02:44) [vital VIT-005268]
- respiratory rate 19/min (2026-11-10 18:44) [vital VIT-005242]
- WBC 8.73 x10^3/uL (2026-11-09 11:24) [lab LAB-001842]
- WBC 7.73 x10^3/uL (2026-11-10 05:00) [lab LAB-001844]
- platelets 214 x10^3/uL (2026-11-10 05:00) [lab LAB-001845]
- bilirubin 0.51 mg/dL (2026-11-09 11:24) [lab LAB-001852]
- MAP 74 mmHg (2026-11-10 18:44) [vital VIT-005277]
- GCS 15 (2026-11-09 10:44) [vital VIT-005262]
- creatinine 3.43 mg/dL (2026-11-11 05:00) [lab LAB-001829]
- creatinine 3.26 mg/dL (pre-admission) (2026-07-24 10:05) [lab LAB-001826]

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

Chronic kidney disease · Specificity gap Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
Malnutrition · Specificity gap Documented “malnourished” (E46); criteria support the more specific Severe protein-calorie malnutrition (acute illness context) (E43).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2068	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00054, ENC-00054.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry dd7d3736b727
1242	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00054, ENC-00054.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 14cbb6cd26ec
500	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00054, ENC-00054.sepsis	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt dab1a4e3e8a2 output 4be4a07a71b8 entry 63570a5dee43