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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Pilar Upfield: Acute kidney injury

ENC-00055 · 73F · Hospital Medicine · admitted Wed Nov 11, 2026 08:30 AM · in hospital · attending Dr. Odette Galloway · resident Dr. Greta Kowalczyk

Clinical validation gap Criteria not met Open In hospital: concurrent review Resident note awaiting attending cosign

Documented “AKI” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.

Documented vs supported

Documented: “AKI” · N17.9 Acute kidney failure, unspecified
Criteria support: criteria not met
Outcome: KDIGO creatinine and urine-output criteria not met
Rule: Acute kidney injury (KDIGO staging) v2026.11-1
Published source: KDIGO Clinical Practice Guideline for Acute Kidney Injury (Kidney Int Suppl 2012;2:19-36) (2012), Recommendations 2.1.1 (definition) and 2.1.2 (staging), Table 2 · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: remove N17.9
Secondary-diagnosis level: CC → removed
MS-DRG (illustrative): 377 GI hemorrhage with MCC → 377 GI hemorrhage with MCC
Relative weight: 1.8280 → 1.8280 (+0.0000)
Codes before: K92.2, N17.9, J96.01, D62, I10, E78.5
Codes after: K92.2, J96.01, D62, I10, E78.5

All open gaps on this encounter together: MS-DRG 377 → 377 (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
Baseline creatinine (mg/dL); most recent pre-admission value within 365 days, else lowest this stay (presumed) most recent pre-admission value within 365 days	0.7	creatinine 0.7 mg/dL (pre-admission) · lab LAB-001854 · 2026-08-06 10:05
Whether a pre-admission baseline exists	True	pre-admission creatinine on file · lab LAB-001854 · 2026-08-06 10:05
Peak creatinine this stay (mg/dL)	0.72	creatinine 0.72 mg/dL (peak this stay) · lab LAB-001855 · 2026-11-11 09:30
Peak / baseline peak / baseline	1.029	creatinine 0.72 mg/dL (peak this stay) · lab LAB-001855 · 2026-11-11 09:30 creatinine 0.7 mg/dL (pre-admission) · lab LAB-001854 · 2026-08-06 10:05
Largest creatinine rise between two values within 48 h (mg/dL) largest rise between two values within 48 hours	0.03	creatinine 0.69 · lab LAB-001856 · 2026-11-12 05:00 creatinine 0.72 · lab LAB-001857 · 2026-11-13 05:00

Rule trace (inputs, thresholds, outcome)

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=1.029, creat_rise_48h=0.03, t.ratio_s1=1.5, t.rise_abs=0.3, t.uo_s1_h=6, uo_hours_lt_0_5=unknown	false
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	anuria_hours=unknown, creat_peak=0.72, creat_ratio=1.029, meets_definition=False, rrt_started=False, t.anuria_h=12, t.ratio_s3=3.0, t.scr_s3=4.0, t.uo_s3_h=24, uo_hours_lt_0_3=unknown	false
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=1.029, t.ratio_s2=2.0, t.uo_s2_h=12, uo_hours_lt_0_5=unknown	false
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	meets_definition=False, stage2=False, stage3=False	0
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.03, rrt_started=False, t.rise_abs=0.3	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	baseline_independent=True, stage=0	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2069); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: kidney function documentation
Encounter: ENC-00055   Patient: Pilar Upfield   To: Dr. Odette Galloway

Clinical indicators from the health record:
- Documented in the record: "AKI" [Progress note DOC-000192]
- creatinine 0.7 mg/dL (pre-admission) (2026-08-06 10:05) [lab LAB-001854]
- creatinine 0.72 mg/dL (peak this stay) (2026-11-11 09:30) [lab LAB-001855]
- creatinine 0.69 (2026-11-12 05:00) [lab LAB-001856]
- creatinine 0.72 (2026-11-13 05:00) [lab LAB-001857]

Question:
The indicators above are documented in this encounter. Could you clarify the status of the documented kidney diagnosis?

Response options (select one or write your own):
( ) AKI: confirmed (please document the supporting clinical information)
( ) AKI: 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 blood loss anaemia · Clinical judgement required Clinical judgement required: Haemoglobin fell 1.4 g/dL without transfusion (between 1 and 2 g/dL).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2069	2026-11-14T20:57:23	system:llm system	`llm.call`	ENC-00055, ENC-00055.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt d773232d67de output 39b351ef64f3 entry 7778146d5a58
1243	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00055, ENC-00055.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt d773232d67de output 39b351ef64f3 entry 320488b362af
501	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00055, ENC-00055.aki	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt d773232d67de output 39b351ef64f3 entry 21ba19816aaf