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Ines Ashgrove: Chronic kidney disease
ENC-00097 · 79F · Cardiology · admitted Sun Nov 01, 2026 10:21 AM · discharged Thu Nov 05, 2026 02:15 PM · attending Dr. Cyrus Ellingham · resident Dr. Camila Oyelaran
Clinical judgement required: Pre-admission eGFR values fall on both sides of 60.
Documented vs supported
- Documented
- “CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- Pre-admission eGFR values fall on both sides of 60
- 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)
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)
- 291 Heart failure and shock with MCC → 291 Heart failure and shock with MCC
- Relative weight
- 1.2838 → 1.2838 (+0.0000)
- Codes before
- I50.9, E43, N18.31
- Codes after
- I50.9, E43, N18.31
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
0.0 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 |
|---|---|---|
| Number of pre-admission eGFR values within 2 years (inpatient values during acute illness are not used) | 2 |
creatinine 1.07 -> eGFR 53
creatinine 0.89 -> eGFR 66
|
| Days between the earliest and latest pre-admission eGFR values | 282 |
creatinine 1.07 mg/dL -> eGFR 53 (CKD-EPI 2021)
creatinine 0.89 mg/dL -> eGFR 66 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 52.8 |
creatinine 1.07 mg/dL -> eGFR 53 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 65.9 |
creatinine 0.89 mg/dL -> eGFR 66 (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=282, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=52.8, egfr_late=65.9 | 65.9 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=52.8, egfr_late=65.9, t.g2=60 | false |
| 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=65.9, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 | G1-G2 |
| 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=False, egfr_early=52.8, egfr_late=65.9, t.g2=60 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2155); 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-00097 Patient: Ines Ashgrove To: Dr. Cyrus Ellingham Clinical indicators from the health record: - Documented in the record: "CKD stage 3a" [History and physical DOC-000328] - creatinine 1.07 -> eGFR 53 (2025-10-13 09:15) [lab LAB-003290] - creatinine 0.89 -> eGFR 66 (2026-07-22 10:05) [lab LAB-003291] Question: Could you review the kidney function indicators above and clarify any related chronic diagnosis, if clinically appropriate? Response options (select one or write your own): ( ) 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
- Heart failure · Specificity gap Documented “congestive heart failure” (I50.9); criteria support the more specific Chronic systolic (HFrEF) heart failure (I50.22).
- Malnutrition · Clinical validation gap Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2155 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00097, ENC-00097.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt cda6e9b07578 output ba86a1b76b41 entry 2e4744e23f34 |
| 1329 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00097, ENC-00097.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt cda6e9b07578 output ba86a1b76b41 entry 7e6c5bcee6dd |
| 587 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00097, ENC-00097.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt cda6e9b07578 output ba86a1b76b41 entry 93ab0c90fbde |