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-00098
Celeste Hartwell: Malnutrition
ENC-00098 · 80M · Hospital Medicine · admitted Sat Nov 07, 2026 10:30 PM · in hospital · attending Dr. Kenji Stavros
Clinical validation gap Criteria met Open
In hospital: concurrent review
Documented “severe protein-calorie malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
Documented vs supported
- Documented
- “severe protein-calorie malnutrition” · E43 Unspecified severe protein-calorie malnutrition
- Criteria support
- Moderate (non-severe) protein-calorie malnutrition (acute illness context) · E44.0 Moderate protein-calorie malnutrition
- Outcome
- 3 moderate-or-worse characteristics, fewer than two severe (acute illness context)
- 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
- E43 -> E44.0
- Secondary-diagnosis level
- MCC → CC
- MS-DRG (illustrative)
- 689 Kidney and urinary tract infections with MCC → 689 Kidney and urinary tract infections with MCC
- Relative weight
- 1.1603 → 1.1603 (+0.0000)
- Codes before
- N39.0, E43, J96.01, E87.1, D62, I10, E78.5
- Codes after
- N39.0, J96.01, E87.1, D62, I10, E78.5, E44.0
All open gaps on this encounter together: MS-DRG 689 → 690 (RW -0.3508).
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 |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | acute |
“Context: acute illness”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Celeste Hartwell MRN: MRN52546438
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneou … |
| Energy intake as % of estimated need | 60.0 |
“estimated energy intake 60% of needs for 9 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Celeste Hartwell MRN: MRN52546438
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip … |
| Duration of reduced intake (days) | 9.0 |
“estimated energy intake 60% of needs for 9 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Celeste Hartwell MRN: MRN52546438
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip … |
| Weight loss (%) | 3.0 |
“3% weight loss over 30 days”
Show the quote in the note… stered Dietitian)
Patient: Celeste Hartwell MRN: MRN52546438
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets cri … |
| Period of the weight loss (days) | 30.0 |
“3% weight loss over 30 days”
Show the quote in the note… stered Dietitian)
Patient: Celeste Hartwell MRN: MRN52546438
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets cri … |
| Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe) | 1 |
“mild loss of subcutaneous fat”
Show the quote in the note…
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition. |
| Muscle mass loss (0-3) | 1 |
“mild muscle wasting”
Show the quote in the note… : estimated energy intake 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition. |
| Fluid accumulation (0-3) | 0 |
“no fluid accumulation”
Show the quote in the note… take 60% of needs for 9 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneous fat; mild muscle wasting; no fluid accumulation.
Grip strength: not assessed.
Assessment: meets criteria for non-severe (moderate) malnutrition. |
Rule trace (inputs, thresholds, outcome)
| 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=9.0, intake_pct=60.0, 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=9.0, intake_pct=60.0, t.a_mod_intake_days=7, t.a_mod_intake_pct=75 | true |
| 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=30.0, wt_loss_pct=3.0 | false |
| 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=30.0, wt_loss_pct=3.0 | false |
| derived: c_sev_intake | intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=9.0, intake_pct=60.0, 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=9.0, intake_pct=60.0, 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=30.0, wt_loss_pct=3.0 | false |
| 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=30.0, wt_loss_pct=3.0 | false |
| derived: n_assessed | known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) |
fat_loss=1, fluid=0, grip_reduced=unknown, intake_pct=60.0, muscle_loss=1, wt_loss_pct=3.0 | 5 |
| 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=False, c_sev_intake=False, c_sev_wt=False, fat_loss=1, fluid=0, grip_reduced=unknown, muscle_loss=1, 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=True, a_mod_wt=False, a_sev_intake=False, a_sev_wt=False, c_mod_intake=False, c_mod_wt=False, c_sev_intake=False, c_sev_wt=False, fat_loss=1, fluid=0, grip_reduced=unknown, muscle_loss=1, nutr_context=acute | 3 |
| outcome: severe | n_severe >= 2 |
n_severe=0 | false |
| outcome: moderate | n_moderate >= 2 |
n_moderate=3 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2160); 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-00098 Patient: Celeste Hartwell To: Dr. Kenji Stavros Clinical indicators from the health record: - Documented in the record: "severe protein-calorie malnutrition" [Progress note DOC-000333] - "Context: acute illness" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 4] - "estimated energy intake 60% of needs for 9 days" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 5] - "estimated energy intake 60% of needs for 9 days" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 5] - "3% weight loss over 30 days" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 6] - "3% weight loss over 30 days" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 6] - "mild loss of subcutaneous fat" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 7] - "mild muscle wasting" (2026-11-09 01:30) [Nutrition assessment DOC-000331, p. 1, line 7] - "no fluid accumulation" (2026-11-09 01:30) [Nutrition assessment DOC-000331, 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): ( ) Severe protein-calorie malnutrition: confirmed (please document the supporting clinical information) ( ) Moderate protein-calorie malnutrition ( ) 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
- Acute kidney injury · Specificity gap Criteria support Acute kidney injury (KDIGO stage 2) (N17.9); no corresponding diagnosis is documented.
- Hyponatraemia · Clinical validation gap Documented “hyponatremia” (E87.1) but the criteria are not met: All sodium values 135 or above (lowest 136).
- Acute respiratory failure · Clinical validation gap Documented “acute respiratory failure with hypoxia” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 93%), oxygen no more than 0 L/min, no advanced support.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2160 | 2026-11-14T20:57:24 | system:llm system |
llm.call |
ENC-00098, ENC-00098.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 18a72efb4154 |
| 1334 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00098, ENC-00098.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 30f0dc2c0cd1 |
| 592 | 2026-11-14T18:29:05 | system:llm system |
llm.call |
ENC-00098, ENC-00098.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry d64012d0aa19 |