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.

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Dmitri Greaves: Hyponatraemia

ENC-00106 · 83F · Hospital Medicine · admitted Mon Nov 09, 2026 12:02 PM · in hospital · attending Dr. Cyrus Ellingham · resident Dr. Noor Halvorsen

Clinical judgement required Clinical judgement required Open In hospital: concurrent review Resident note awaiting attending cosign

Clinical judgement required: Low sodium without documented treatment or repeat values; clinical significance is a clinician judgement.

Documented vs supported

Documented: “hyponatremia” · E87.1 Hypo-osmolality and hyponatremia
Criteria support: no conclusion: clinical judgement required
Outcome: Low sodium without documented treatment or repeat values; clinical significance is a clinician judgement
Rule: Hyponatraemia v2026.11-1
Published source: Clinical practice guideline on diagnosis and treatment of hyponatraemia (Spasovski et al., Eur J Endocrinol 2014;170:G1-G47) (2014), Classification by biochemical severity: mild 130-135, moderate 125-129, profound <125 mmol/L · 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: 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, E46, I50.23, E87.1, I10, E78.5
Codes after: N39.0, E46, I50.23, E87.1, I10, E78.5

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

0.0 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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Lowest serum sodium this stay (mmol/L)	133.0	sodium 133 mmol/L · lab LAB-003598 · 2026-11-09 13:02
Number of sodium values below 135	1	sodium 133 · lab LAB-003598 · 2026-11-09 13:02

Rule trace (inputs, thresholds, outcome)

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=133.0, t.low=135, t.moderate=130, t.profound=125	mild
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_low_count=1, na_min=133.0, na_treated=False, t.low=135, t.repeat=2	false
outcome: untreated	`na_min < t.low`	na_min=133.0, t.low=135	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2177); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: electrolyte documentation
Encounter: ENC-00106   Patient: Dmitri Greaves   To: Dr. Cyrus Ellingham

Clinical indicators from the health record:
- Documented in the record: "hyponatremia" [Progress note DOC-000358]
- sodium 133 mmol/L (2026-11-09 13:02) [lab LAB-003598]

Question:
Could you review the sodium values above and clarify their clinical significance, if any?

Response options (select one or write your own):
( ) Hyponatremia (please specify cause, if known)
( ) 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

Chronic kidney disease · Specificity gap Criteria support Chronic kidney disease stage 3a (N18.31); no corresponding diagnosis is documented.
Heart failure · Clinical validation gap Documented “acute on chronic systolic heart failure” (I50.23) is more specific than the criteria support (Chronic systolic (HFrEF) heart failure, I50.22).
Malnutrition · Specificity gap Documented “malnourished” (E46); criteria support the more specific Moderate (non-severe) protein-calorie malnutrition (chronic illness context) (E44.0).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2177	2026-11-14T20:57:25	system:llm system	`llm.call`	ENC-00106, ENC-00106.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b490130e78a9 output 87f72fd19df7 entry 361ee1dbdb1f
1351	2026-11-14T19:24:30	system:llm system	`llm.call`	ENC-00106, ENC-00106.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b490130e78a9 output 87f72fd19df7 entry ddd9f87b4f11
609	2026-11-14T18:29:05	system:llm system	`llm.call`	ENC-00106, ENC-00106.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt b490130e78a9 output 87f72fd19df7 entry 64ee5907df8b