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-00064
Keira Merriweather: Malnutrition
ENC-00064 · 70F · Hospital Medicine · admitted Sat Nov 07, 2026 08:22 AM · in hospital · attending Dr. Cyrus Ellingham · resident Dr. Keira Upfield
Specificity gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Criteria support Severe protein-calorie malnutrition (chronic illness context) (E43); no corresponding diagnosis is documented.
Documented vs supported
- Documented
- not documented
- Criteria support
- Severe protein-calorie malnutrition (chronic illness context) · E43 Unspecified severe protein-calorie malnutrition
- Outcome
- 3 severe characteristics (chronic 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
- add E43
- Secondary-diagnosis level
- — → MCC
- MS-DRG (illustrative)
- 195 Simple pneumonia and pleurisy without CC/MCC → 193 Simple pneumonia and pleurisy with MCC
- Relative weight
- 0.6285 → 1.3144 (+0.6859)
- Codes before
- J18.9, D64.9, E78.5
- Codes after
- J18.9, D64.9, E78.5, E43
All open gaps on this encounter together: MS-DRG 195 → 193 (RW +0.6859).
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 |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | chronic |
“Context: chronic illness”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Keira Merriweather MRN: MRN61729870
Context: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subc … |
| Energy intake as % of estimated need | 60.0 |
“estimated energy intake 60% of needs for 55 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Keira Merriweather MRN: MRN61729870
Context: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat … |
| Duration of reduced intake (days) | 55.0 |
“estimated energy intake 60% of needs for 55 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Keira Merriweather MRN: MRN61729870
Context: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulat … |
| Weight loss (%) | 12.8 |
“12.8% weight loss over 180 days”
Show the quote in the note… d Dietitian)
Patient: Keira Merriweather MRN: MRN61729870
Context: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplemen … |
| Period of the weight loss (days) | 180.0 |
“12.8% weight loss over 180 days”
Show the quote in the note… d Dietitian)
Patient: Keira Merriweather MRN: MRN61729870
Context: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplemen … |
| Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe) | 3 |
“severe loss of subcutaneous fat”
Show the quote in the note… xt: chronic illness
Intake: estimated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
Recommendations: high-protein oral supplement; calorie counts; weekly weights. |
| Muscle mass loss (0-3) | 2 |
“moderate muscle wasting”
Show the quote in the note… ated energy intake 60% of needs for 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
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 55 days.
Weight history: 12.8% weight loss over 180 days.
Nutrition-focused physical exam: severe loss of subcutaneous fat; moderate muscle wasting; no fluid accumulation.
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=55.0, intake_pct=60.0, t.a_sev_intake_days=5, t.a_sev_intake_pct=50 | false |
| derived: a_mod_intake | intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days |
intake_days=55.0, intake_pct=60.0, 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=180.0, wt_loss_pct=12.8 | false |
| 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=180.0, wt_loss_pct=12.8 | false |
| derived: c_sev_intake | intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=55.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75 | true |
| derived: c_mod_intake | intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=55.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75 | true |
| 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=180.0, wt_loss_pct=12.8 | 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=180.0, wt_loss_pct=12.8 | true |
| derived: n_assessed | known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) |
fat_loss=3, fluid=0, grip_reduced=unknown, intake_pct=60.0, muscle_loss=2, wt_loss_pct=12.8 | 5 |
| 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=False, a_sev_wt=False, c_sev_intake=True, c_sev_wt=True, fat_loss=3, fluid=0, grip_reduced=unknown, muscle_loss=2, nutr_context=chronic | 3 |
| 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=False, a_sev_intake=False, a_sev_wt=False, c_mod_intake=True, c_mod_wt=True, c_sev_intake=True, c_sev_wt=True, fat_loss=3, fluid=0, grip_reduced=unknown, muscle_loss=2, nutr_context=chronic | 4 |
| outcome: severe | n_severe >= 2 |
n_severe=3 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2091); 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-00064 Patient: Keira Merriweather To: Dr. Cyrus Ellingham Clinical indicators from the health record: - "Context: chronic illness" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 4] - "estimated energy intake 60% of needs for 55 days" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 5] - "estimated energy intake 60% of needs for 55 days" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 5] - "12.8% weight loss over 180 days" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 6] - "12.8% weight loss over 180 days" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 6] - "severe loss of subcutaneous fat" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 7] - "moderate muscle wasting" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 7] - "no fluid accumulation" (2026-11-08 13:22) [Nutrition assessment DOC-000221, p. 1, line 7] 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
- Acute blood loss anaemia · Specificity gap Documented “anemia” (D64.9); criteria support the more specific Acute blood loss anemia (D62).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2091 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00064, ENC-00064.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry fa574f13053c |
| 1265 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00064, ENC-00064.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry c1af584eccaa |
| 523 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00064, ENC-00064.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt d06d622e0ef6 output de34f00338d8 entry ed70b13dadc4 |