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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Lena Upfield: Hyponatraemia

ENC-00065 · 51M · Hospital Medicine · admitted Tue Nov 10, 2026 03:47 PM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Camila Oyelaran

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

Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.

Documented vs supported

Documented: not documented
Criteria support: Hyponatraemia (moderate) · E87.1 Hypo-osmolality and hyponatremia
Outcome: Sodium below 135 on 4 values (lowest 128, moderate) with treatment ordered
Rule: Hyponatraemia v2026.11-1
Published source: Clinical practice guideline on diagnosis and treatment of hyponatraemia (Spasovski et al., Eur J Endocrinol 2014;170:G1-G47) (2014), Classification by biochemical severity: mild 130-135, moderate 125-129, profound <125 mmol/L · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: add E87.1
Secondary-diagnosis level: — → CC
MS-DRG (illustrative): 193 Simple pneumonia and pleurisy with MCC → 193 Simple pneumonia and pleurisy with MCC
Relative weight: 1.3144 → 1.3144 (+0.0000)
Codes before: J18.9, E43, N18.9, I50.30, R09.02, D64.9
Codes after: J18.9, E43, N18.9, I50.30, R09.02, D64.9, E87.1

All open gaps on this encounter together: MS-DRG 193 → 193 (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
Lowest serum sodium this stay (mmol/L)	128.0	sodium 128 mmol/L · lab LAB-002196 · 2026-11-11 05:00
Number of sodium values below 135	4	sodium 130 · lab LAB-002195 · 2026-11-10 16:47 sodium 128 · lab LAB-002196 · 2026-11-11 05:00 sodium 129 · lab LAB-002197 · 2026-11-12 05:00 sodium 132 · lab LAB-002198 · 2026-11-13 05:00
Fluid restriction, salt tablets, hypertonic saline or a vaptan ordered	True	fluid restriction 1.2 L/day · order ORD-000055 · 2026-11-10 18:47

Rule trace (inputs, thresholds, outcome)

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=128.0, t.low=135, t.moderate=130, t.profound=125	moderate
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_low_count=4, na_min=128.0, na_treated=True, t.low=135, t.repeat=2	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2095); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: electrolyte documentation
Encounter: ENC-00065   Patient: Lena Upfield   To: Dr. Rosalind Quillan

Clinical indicators from the health record:
- sodium 128 mmol/L (2026-11-11 05:00) [lab LAB-002196]
- sodium 130 (2026-11-10 16:47) [lab LAB-002195]
- sodium 129 (2026-11-12 05:00) [lab LAB-002197]
- sodium 132 (2026-11-13 05:00) [lab LAB-002198]
- fluid restriction 1.2 L/day (2026-11-10 18:47) [order ORD-000055]

Question:
Based on your clinical judgement and the indicators above, can a related diagnosis be documented?

Response options (select one or write your own):
( ) Hyponatremia (please specify cause, if known)
( ) 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).
Chronic kidney disease · Specificity gap Documented “chronic kidney disease” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).
Heart failure · Specificity gap Documented “diastolic heart failure” (I50.30); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
Malnutrition · Clinical validation gap Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (chronic illness context), E44.0).
Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2095	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00065, ENC-00065.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 300e15d9f73a output 1529a3e2b70e entry 25e834792d58
1269	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00065, ENC-00065.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 300e15d9f73a output 1529a3e2b70e entry d141c1c04b2c
527	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00065, ENC-00065.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 300e15d9f73a output 1529a3e2b70e entry 727bf2245be9