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Viggo Pemberton: Acute respiratory failure
ENC-00095 · 60M · Cardiology · admitted Tue Nov 10, 2026 05:58 PM · in hospital · attending Dr. Cyrus Ellingham · resident Dr. Elena Nakashima
Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.
Documented vs supported
- Documented
- “hypoxemia” · R09.02 Hypoxemia
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- Hypoxaemia without a charted sign of respiratory distress
- Rule
- Acute hypoxic respiratory failure v2026.11-1
- Published source
- Merck Manual Professional Version: Acute Hypoxemic Respiratory Failure (AHRF), including ARDS (2026), Definition/evaluation: PaO2 <60 mmHg, PaO2/FiO2 <300, or SpO2 <88%, with dyspnea and tachypnea · source (checked 2026-11-14)
- Contested
- Organizations use different oxygen-saturation cut-offs (SpO2 <88%, <=90% or <91% on room air). This rule uses <88% (the source above) and a LOCAL respiratory-rate cut-off of 28/min as one sign of respiratory distress.
Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.
Effect if the clinician agrees (illustrative)
- Change
- no projected change (clinician judgement)
- Secondary-diagnosis level
- non-CC → —
- MS-DRG (illustrative)
- 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
- Relative weight
- 0.8490 → 0.8490 (+0.0000)
- Codes before
- I50.23, E66.813, R09.02, D62, E78.5
- Codes after
- I50.23, E66.813, R09.02, D62, E78.5
All open gaps on this encounter together: MS-DRG 292 → 292 (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
0.0 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.
| Input | Value | Source |
|---|---|---|
| Lowest SpO2 on room air (%) | 87.0 |
SpO2 87% on room air
|
| Highest respiratory rate (/min) | 23.0 |
respiratory rate 23/min
|
| Highest supplemental oxygen flow (L/min) | 2.0 |
O2 2 L/min (nasal cannula)
|
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: measured | present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min) |
pao2_min_ra=unknown, pf_min=unknown, spo2_min_ra=87.0 | true |
| derived: hypoxemia | coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false) |
pao2_min_ra=unknown, pf_min=unknown, spo2_min_ra=87.0, t.pao2=60, t.pf=300, t.spo2_ra=88 | true |
| derived: distress | coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support |
adv_resp_support=False, rr_max=23.0, t.rr_distress=28, wob_increased=unknown | false |
| outcome: chronic_baseline | home_o2 and hypoxemia |
home_o2=False, hypoxemia=True | false |
| outcome: met | hypoxemia and distress |
distress=False, hypoxemia=True | false |
| outcome: hypoxemia_only | hypoxemia |
hypoxemia=True | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2154); clinical indicators and answer options assembled by code from the rule and the record.
Sign in to act. Sign in as a demo user (a CDI specialist sends queries).
DOCUMENTATION QUERY (draft) Title: Clarification request: respiratory documentation Encounter: ENC-00095 Patient: Viggo Pemberton To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "hypoxemia" [Progress note DOC-000323] - SpO2 87% on room air (2026-11-10 18:18) [vital VIT-009293] - respiratory rate 23/min (2026-11-10 18:18) [vital VIT-009294] - O2 2 L/min (nasal cannula) (2026-11-11 02:18) [vital VIT-009297] Question: Could you review the respiratory indicators above and clarify any related diagnosis, if clinically appropriate? Response options (select one or write your own): ( ) Acute respiratory failure with hypoxia ( ) Hypoxemia without respiratory failure ( ) 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 kidney injury · Specificity gap Criteria support Acute kidney injury (KDIGO stage 3) (N17.9); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2154 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00095, ENC-00095.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt fd4ead32b26b output c1df7b9475f4 entry b27bc359a5b4 |
| 1328 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00095, ENC-00095.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt fd4ead32b26b output c1df7b9475f4 entry 921dccc6831d |
| 586 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00095, ENC-00095.respiratory_failure | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt fd4ead32b26b output c1df7b9475f4 entry 0acd09c64fda |