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-00090

Farah Nakashima: Malnutrition

ENC-00090 · 78F · Cardiology · admitted Wed Nov 04, 2026 06:58 PM · discharged Mon Nov 09, 2026 03:19 PM · attending Dr. Gideon Zeller

Clinical validation gap Criteria not met Open

Documented “malnourished” (E46) but the criteria are not met: 4 characteristics assessed and none met.

Documented vs supported

Documented: “malnourished” · E46 Unspecified protein-calorie malnutrition
Criteria support: criteria not met
Outcome: 4 characteristics assessed and none met
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: remove E46
Secondary-diagnosis level: CC → removed
MS-DRG (illustrative): 291 Heart failure and shock with MCC → 291 Heart failure and shock with MCC
Relative weight: 1.2838 → 1.2838 (+0.0000)
Codes before: I50.31, E46, N17.9, L89.154, E11.9, K21.9
Codes after: I50.31, N17.9, L89.154, E11.9, K21.9

All open gaps on this encounter together: MS-DRG 291 → 292 (RW -0.4348).

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
Context from the dietitian assessment ("acute" or "chronic" illness)	acute	“Context: acute illness” · Nutrition assessment DOC-000304, p. 1, line 4 · quoted span verified Show the quote in the note NUTRITION ASSESSMENT (Registered Dietitian) Patient: Farah Nakashima MRN: MRN80931376 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle was …
Energy intake as % of estimated need	100.0	“eating 100% of meals” · Nutrition assessment DOC-000304, p. 1, line 5 · quoted span verified Show the quote in the note NUTRITION ASSESSMENT (Registered Dietitian) Patient: Farah Nakashima MRN: MRN80931376 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe)	0	“no loss of subcutaneous fat” · Nutrition assessment DOC-000304, p. 1, line 7 · quoted span verified Show the quote in the note … MRN: MRN80931376 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
Muscle mass loss (0-3)	0	“no muscle wasting” · Nutrition assessment DOC-000304, p. 1, line 7 · quoted span verified Show the quote in the note … acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.
Fluid accumulation (0-3)	0	“no fluid accumulation” · Nutrition assessment DOC-000304, p. 1, line 7 · quoted span verified Show the quote in the note … e: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: well nourished; no malnutrition identified.

Rule trace (inputs, thresholds, outcome)

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
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=100.0, 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=unknown, intake_pct=100.0, t.a_mod_intake_days=7, t.a_mod_intake_pct=75	false
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=100.0, t.c_intake_days=30, t.c_intake_pct=75	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_days=unknown, intake_pct=100.0, t.c_intake_days=30, t.c_intake_pct=75	false
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=0, fluid=0, grip_reduced=unknown, intake_pct=100.0, muscle_loss=0, wt_loss_pct=unknown	4
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=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute	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=False, a_mod_wt=unknown, a_sev_intake=False, a_sev_wt=unknown, c_mod_intake=False, c_mod_wt=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute	0
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=0	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=0	false
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_assessed=4, n_moderate=0	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2143); 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-00090   Patient: Farah Nakashima   To: Dr. Gideon Zeller

Clinical indicators from the health record:
- Documented in the record: "malnourished" [Progress note DOC-000307]
- "Context: acute illness" (2026-11-05 21:58) [Nutrition assessment DOC-000304, p. 1, line 4]
- "eating 100% of meals" (2026-11-05 21:58) [Nutrition assessment DOC-000304, p. 1, line 5]
- "no loss of subcutaneous fat" (2026-11-05 21:58) [Nutrition assessment DOC-000304, p. 1, line 7]
- "no muscle wasting" (2026-11-05 21:58) [Nutrition assessment DOC-000304, p. 1, line 7]
- "no fluid accumulation" (2026-11-05 21:58) [Nutrition assessment DOC-000304, p. 1, line 7]

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):
( ) Malnourished: confirmed (please document the supporting clinical information)
( ) Malnourished: 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

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

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2143	2026-11-14T20:57:24	system:llm system	`llm.call`	ENC-00090, ENC-00090.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 72ce5e65263c
1317	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00090, ENC-00090.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 1c36cbff8577
575	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00090, ENC-00090.malnutrition	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 94c72d7bb5eb