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).
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← Back to the worklist · Whole encounter ENC-00126
Yusuf Pemberton: Malnutrition
ENC-00126 · 63M · Hospital Medicine · admitted Thu Nov 05, 2026 02:37 PM · discharged Tue Nov 10, 2026 11:27 AM · attending Dr. Gideon Zeller · resident Dr. Noor Halvorsen
Clinical validation gap Criteria met Open
Documented “severe malnutrition” (E43) conflicts with what the criteria support (Moderate (non-severe) protein-calorie malnutrition (acute illness context), E44.0).
Documented vs supported
- Documented
- “severe 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)
- 193 Simple pneumonia and pleurisy with MCC → 194 Simple pneumonia and pleurisy with CC
- Relative weight
- 1.3144 → 0.8059 (-0.5085)
- Codes before
- J18.9, E43, E78.5
- Codes after
- J18.9, E78.5, E44.0
All open gaps on this encounter together: MS-DRG 193 → 193 (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 |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | acute |
“Context: acute illness”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Yusuf Pemberton MRN: MRN26877064
Context: acute illness
Intake: estimated energy intake 60% of needs for 12 days.
Weight history: 3% weight loss over 30 days.
Nutrition-focused physical exam: mild loss of subcutaneo … |
| Energy intake as % of estimated need | 60.0 |
“estimated energy intake 60% of needs for 12 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Yusuf Pemberton MRN: MRN26877064
Context: acute illness
Intake: estimated energy intake 60% of needs for 12 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) | 12.0 |
“estimated energy intake 60% of needs for 12 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Yusuf Pemberton MRN: MRN26877064
Context: acute illness
Intake: estimated energy intake 60% of needs for 12 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: Yusuf Pemberton MRN: MRN26877064
Context: acute illness
Intake: estimated energy intake 60% of needs for 12 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: Yusuf Pemberton MRN: MRN26877064
Context: acute illness
Intake: estimated energy intake 60% of needs for 12 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 12 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 12 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… ake 60% of needs for 12 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=12.0, 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=12.0, 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=12.0, 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=12.0, 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 #2210); 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-00126 Patient: Yusuf Pemberton To: Dr. Gideon Zeller Clinical indicators from the health record: - Documented in the record: "severe malnutrition" [Progress note DOC-000427] - "Context: acute illness" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 4] - "estimated energy intake 60% of needs for 12 days" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 5] - "estimated energy intake 60% of needs for 12 days" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 5] - "3% weight loss over 30 days" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 6] - "3% weight loss over 30 days" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 6] - "mild loss of subcutaneous fat" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 7] - "mild muscle wasting" (2026-11-06 17:37) [Nutrition assessment DOC-000425, p. 1, line 7] - "no fluid accumulation" (2026-11-06 17:37) [Nutrition assessment DOC-000425, 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 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 respiratory failure · Specificity gap Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2210 | 2026-11-14T20:57:25 | system:llm system |
llm.call |
ENC-00126, ENC-00126.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry c3888d1b3997 |
| 1384 | 2026-11-14T19:24:30 | system:llm system |
llm.call |
ENC-00126, ENC-00126.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry f51f7fa18be2 |
| 642 | 2026-11-14T18:29:06 | system:llm system |
llm.call |
ENC-00126, ENC-00126.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 660c3e4baa90 output 50433f2a28f4 entry 2dc8f625020c |