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Pilar Kestrel: Chronic kidney disease
ENC-00092 · 78M · Hospital Medicine · admitted Sat Oct 31, 2026 11:04 AM · discharged Sat Nov 07, 2026 11:56 AM · attending Dr. Cyrus Ellingham
Criteria support Chronic kidney disease stage 4 (N18.4); no corresponding diagnosis is documented.
Documented vs supported
- Documented
- not documented
- Criteria support
- Chronic kidney disease stage 4 · N18.4 Chronic kidney disease, stage 4 (severe)
- Outcome
- Two eGFR values >=90 days apart; staging value 25.2 (G4)
- Rule
- Chronic kidney disease stage (eGFR, CKD-EPI 2021) v2026.11-1
- Published source
- KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (2024), Chapter 1, Table 1 (definition: abnormality for a minimum of 3 months) and Table 2 (GFR categories) · source (checked 2026-11-14)
Effect if the clinician agrees (illustrative)
- Change
- add N18.4
- Secondary-diagnosis level
- — → CC
- MS-DRG (illustrative)
- 871 Septicemia or severe sepsis without MV >96 hours with MCC → 871 Septicemia or severe sepsis without MV >96 hours with MCC
- Relative weight
- 1.9425 → 1.9425 (+0.0000)
- Codes before
- A41.9, J18.9, E66.813, E11.9, E78.5
- Codes after
- A41.9, J18.9, E66.813, E11.9, E78.5, N18.4
All open gaps on this encounter together: MS-DRG 871 → 871 (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 |
|---|---|---|
| Number of pre-admission eGFR values within 2 years (inpatient values during acute illness are not used) | 2 |
creatinine 2.86 -> eGFR 22
creatinine 2.54 -> eGFR 25
|
| Days between the earliest and latest pre-admission eGFR values | 344 |
creatinine 2.86 mg/dL -> eGFR 22 (CKD-EPI 2021)
creatinine 2.54 mg/dL -> eGFR 25 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 21.8 |
creatinine 2.86 mg/dL -> eGFR 22 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 25.2 |
creatinine 2.54 mg/dL -> eGFR 25 (CKD-EPI 2021)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: chronic | egfr_n >= 2 and egfr_span_days >= t.chronic_days |
egfr_n=2, egfr_span_days=344, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=21.8, egfr_late=25.2 | 25.2 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=21.8, egfr_late=25.2, t.g2=60 | true |
| derived: category | case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5') |
staging_egfr=25.2, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 | G4 |
| outcome: duration_not_shown | not chronic |
chronic=True | false |
| outcome: straddles_60 | not both_below_60 and min(egfr_early, egfr_late) < t.g2 |
both_below_60=True, egfr_early=21.8, egfr_late=25.2, t.g2=60 | false |
| outcome: g1_g2 | staging_egfr >= t.g2 |
staging_egfr=25.2, t.g2=60 | false |
| outcome: g3a | category == 'G3a' |
category=G4 | false |
| outcome: g3b | category == 'G3b' |
category=G4 | false |
| outcome: g4 | category == 'G4' |
category=G4 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2146); clinical indicators and answer options assembled by code from the rule and the record.
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DOCUMENTATION QUERY (draft) Title: Clarification request: chronic kidney documentation Encounter: ENC-00092 Patient: Pilar Kestrel To: Dr. Cyrus Ellingham Clinical indicators from the health record: - creatinine 2.86 -> eGFR 22 (2025-10-11 09:15) [lab LAB-003116] - creatinine 2.54 -> eGFR 25 (2026-09-20 10:05) [lab LAB-003117] Question: Based on your clinical judgement and the indicators above, can the chronic kidney condition be further specified, including stage if known? Response options (select one or write your own): ( ) Chronic kidney disease stage 3b (eGFR 30-44) ( ) Chronic kidney disease stage 4 (eGFR 15-29) ( ) 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
- Sepsis · Clinical judgement required Clinical judgement required: Definition-dependent: 3 SIRS criteria (Sepsis-2 met) but SOFA change only 0 (Sepsis-3 not met).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2146 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00092, ENC-00092.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 16c0f80e6a26 |
| 1320 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00092, ENC-00092.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 528183072568 |
| 578 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00092, ENC-00092.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 1350772b12af |