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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Jun Galloway: Pressure injury

ENC-00067 · 73M · Hospital Medicine · admitted Sun Nov 08, 2026 06:57 PM · in hospital · attending Dr. Cyrus Ellingham

Clinical validation gap Criteria met Open In hospital: concurrent review

Documented “stage 4 sacral pressure ulcer” (L89.154) conflicts with what the criteria support (Pressure injury of sacral region, stage 2, L89.152).

Documented vs supported

Documented: “stage 4 sacral pressure ulcer” · L89.154 Pressure ulcer of sacral region, stage 4
Criteria support: Pressure injury of sacral region, stage 2 · L89.152 Pressure ulcer of sacral region, stage 2
Outcome: Wound nurse documents stage 2, sacral
Rule: Pressure injury stage (sacral region) v2026.11-1
Published source: NPIAP Pressure Injury Stages (revised staging system) (2016), Stage 1-4, unstageable, deep tissue pressure injury definitions · source (checked 2026-11-14)

Effect if the clinician agrees (illustrative)

Change: L89.154 -> L89.152
Secondary-diagnosis level: MCC → non-CC
MS-DRG (illustrative): 193 Simple pneumonia and pleurisy with MCC → 195 Simple pneumonia and pleurisy without CC/MCC
Relative weight: 1.3144 → 0.6285 (-0.6859)
Codes before: J18.9, E66.9, N18.32, I50.9, L89.154
Codes after: J18.9, E66.9, N18.32, I50.9, L89.152

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

-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
Stage quoted from the wound-care note	2	“Stage: 2” · Wound care note DOC-000230, p. 1, line 5 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Jun Galloway MRN: MRN61396891 Location: sacrum Stage: 2 (NPIAP) Description: partial-thickness skin loss with exposed dermis. Size: 4.9 x 3.0 x 0.8 cm. Plan: offloading every 2 hours, foam dressing, nutrition consul …
Site quoted from the wound-care note	sacral	“Location: sacrum” · Wound care note DOC-000230, p. 1, line 4 · quoted span verified Show the quote in the note WOUND CARE NOTE Patient: Jun Galloway MRN: MRN61396891 Location: sacrum Stage: 2 (NPIAP) Description: partial-thickness skin loss with exposed dermis. Size: 4.9 x 3.0 x 0.8 cm. Plan: offloading every 2 hours, foam dressing, nutriti …

Rule trace (inputs, thresholds, outcome)

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=sacral	true
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=2	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=2	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=2	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2101); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: skin integrity documentation
Encounter: ENC-00067   Patient: Jun Galloway   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "stage 4 sacral pressure ulcer" [Progress note DOC-000232]
- "Stage: 2" (2026-11-09 20:57) [Wound care note DOC-000230, p. 1, line 5]
- "Location: sacrum" (2026-11-09 20:57) [Wound care note DOC-000230, p. 1, line 4]

Question:
The wound-care documentation above differs from the provider documentation. Could you clarify the site and stage of the documented skin condition?

Response options (select one or write your own):
( ) Stage 4 sacral pressure ulcer: confirmed (please document the supporting clinical information)
( ) Pressure ulcer of sacral region, stage 2
( ) 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

Heart failure · Specificity gap Documented “heart failure” (I50.9); criteria support the more specific Acute on chronic diastolic (HFpEF) heart failure (I50.33).
Hyponatraemia · Specificity gap Criteria support Hyponatraemia (profound) (E87.1); no corresponding diagnosis is documented.
Obesity · Specificity gap Documented “obesity” (E66.9); criteria support the more specific Obesity, class 3 (E66.813).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2101	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00067, ENC-00067.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 70e56f9b1005 output e3e4996fd0a8 entry b3d2bcdb5f33
1275	2026-11-14T19:24:29	system:llm system	`llm.call`	ENC-00067, ENC-00067.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 70e56f9b1005 output e3e4996fd0a8 entry e306bf872879
533	2026-11-14T18:29:04	system:llm system	`llm.call`	ENC-00067, ENC-00067.pressure_injury	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 70e56f9b1005 output e3e4996fd0a8 entry 93573bcfdcc9