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-00065
Lena Upfield: Malnutrition
ENC-00065 · 51M · Hospital Medicine · admitted Tue Nov 10, 2026 03:47 PM · in hospital · attending Dr. Rosalind Quillan · resident Dr. Camila Oyelaran
Clinical validation gap Criteria met Open
In hospital: concurrent review Resident note awaiting attending cosign
Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (chronic illness context), E44.0).
Documented vs supported
- Documented
- “severe malnutrition” · E43 Unspecified severe protein-calorie malnutrition
- Criteria support
- Moderate (non-severe) protein-calorie malnutrition (chronic illness context) · E44.0 Moderate protein-calorie malnutrition
- Outcome
- 2 moderate-or-worse characteristics, fewer than two severe (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
- E43 -> E44.0
- Secondary-diagnosis level
- MCC → CC
- MS-DRG (illustrative)
- 193 Simple pneumonia and pleurisy with MCC → 194 Simple pneumonia and pleurisy with CC
- Relative weight
- 1.3144 → 0.8059 (-0.5085)
- Codes before
- J18.9, E43, N18.9, I50.30, R09.02, D64.9
- Codes after
- J18.9, N18.9, I50.30, R09.02, D64.9, E44.0
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.
| Input | Value | Source |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | chronic |
“setting of chronic illness”
Show the quote in the noteRD follow-up note
Pt seen in the setting of chronic illness. Eating about half of meals for the past 7 weeks. Weight 54.4 kg, down from 60.5 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No e … |
| Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe) | 1 |
“mild fat loss”
Show the quote in the note… in the setting of chronic illness. Eating about half of meals for the past 7 weeks. Weight 54.4 kg, down from 60.5 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No edema. Hand grip not assessed.
Plan: oral supplement twice daily; recheck weight weekly. |
| Muscle mass loss (0-3) | 1 |
“Mild temporal wasting”
Show the quote in the note… follow-up note
Pt seen in the setting of chronic illness. Eating about half of meals for the past 7 weeks. Weight 54.4 kg, down from 60.5 kg three months ago. Mild temporal wasting; mild fat loss at the triceps. No edema. Hand grip not assessed.
Plan: oral supplement twice daily; recheck weight weekly. |
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=unknown, intake_pct=unknown, t.a_sev_intake_days=5, t.a_sev_intake_pct=50 | unknown |
| derived: a_mod_intake | intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days |
intake_days=unknown, intake_pct=unknown, t.a_mod_intake_days=7, t.a_mod_intake_pct=75 | unknown |
| 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=unknown, wt_loss_pct=unknown | unknown |
| 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=unknown, wt_loss_pct=unknown | unknown |
| derived: c_sev_intake | intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=unknown, intake_pct=unknown, t.c_intake_days=30, t.c_intake_pct=75 | unknown |
| derived: c_mod_intake | intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=unknown, intake_pct=unknown, t.c_intake_days=30, t.c_intake_pct=75 | unknown |
| 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=unknown, wt_loss_pct=unknown | unknown |
| 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=unknown, wt_loss_pct=unknown | unknown |
| derived: n_assessed | known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) |
fat_loss=1, fluid=unknown, grip_reduced=unknown, intake_pct=unknown, muscle_loss=1, wt_loss_pct=unknown | 2 |
| 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=unknown, a_sev_wt=unknown, c_sev_intake=unknown, c_sev_wt=unknown, fat_loss=1, fluid=unknown, grip_reduced=unknown, muscle_loss=1, nutr_context=chronic | 0 |
| 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=unknown, a_mod_wt=unknown, a_sev_intake=unknown, a_sev_wt=unknown, c_mod_intake=unknown, c_mod_wt=unknown, c_sev_intake=unknown, c_sev_wt=unknown, fat_loss=1, fluid=unknown, grip_reduced=unknown, muscle_loss=1, nutr_context=chronic | 2 |
| outcome: severe | n_severe >= 2 |
n_severe=0 | false |
| outcome: moderate | n_moderate >= 2 |
n_moderate=2 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2096); 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-00065 Patient: Lena Upfield To: Dr. Rosalind Quillan Clinical indicators from the health record: - Documented in the record: "severe malnutrition" [Progress note DOC-000226] - "setting of chronic illness" (2026-11-11 18:47) [Nutrition assessment DOC-000224, p. 1, line 3] - "mild fat loss" (2026-11-11 18:47) [Nutrition assessment DOC-000224, p. 1, line 3] - "Mild temporal wasting" (2026-11-11 18:47) [Nutrition assessment DOC-000224, p. 1, line 3] Question: The nutrition indicators above are documented in this encounter. Could you clarify the status and severity of the documented nutritional diagnosis? Response options (select one or write your own): ( ) Severe malnutrition: confirmed (please document the supporting clinical information) ( ) Moderate protein-calorie malnutrition ( ) 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 · 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).
- Hyponatraemia · Specificity gap Criteria support Hyponatraemia (moderate) (E87.1); no corresponding diagnosis is documented.
- Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2096 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00065, ENC-00065.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 5ddfdb67dc83 |
| 1270 | 2026-11-14T19:24:29 | system:llm system |
llm.call |
ENC-00065, ENC-00065.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry a6d7a7c56a8f |
| 528 | 2026-11-14T18:29:04 | system:llm system |
llm.call |
ENC-00065, ENC-00065.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry d637b7ee6e0d |