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Amara Holloway: Chronic kidney disease
ENC-00136 · 79F · Hospital Medicine · admitted Thu Nov 05, 2026 10:43 AM · discharged Sun Nov 08, 2026 10:07 AM · attending Dr. Gideon Zeller · resident Dr. Elena Nakashima
Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 3b (N18.32).
Documented vs supported
- Documented
- “CKD” · N18.9 Chronic kidney disease, unspecified
- Criteria support
- Chronic kidney disease stage 3b · N18.32 Chronic kidney disease, stage 3b
- Outcome
- Two eGFR values >=90 days apart, both below 60; staging value 38.9 (G3b)
- 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)
Effect if the clinician agrees (illustrative)
- Change
- N18.9 -> N18.32
- Secondary-diagnosis level
- non-CC → non-CC
- MS-DRG (illustrative)
- 194 Simple pneumonia and pleurisy with CC → 194 Simple pneumonia and pleurisy with CC
- Relative weight
- 0.8059 → 0.8059 (+0.0000)
- Codes before
- J18.9, E66.813, N18.9, N17.9, E78.5, E11.9, I10
- Codes after
- J18.9, E66.813, N17.9, E78.5, E11.9, I10, N18.32
All open gaps on this encounter together: MS-DRG 194 → 194 (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 |
|---|---|---|
| Number of pre-admission eGFR values within 2 years (inpatient values during acute illness are not used) | 2 |
creatinine 1.47 -> eGFR 36
creatinine 1.38 -> eGFR 39
|
| Days between the earliest and latest pre-admission eGFR values | 284 |
creatinine 1.47 mg/dL -> eGFR 36 (CKD-EPI 2021)
creatinine 1.38 mg/dL -> eGFR 39 (CKD-EPI 2021)
|
| Earliest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 36.1 |
creatinine 1.47 mg/dL -> eGFR 36 (CKD-EPI 2021)
|
| Latest pre-admission eGFR (mL/min/1.73 m2, CKD-EPI 2021) | 38.9 |
creatinine 1.38 mg/dL -> eGFR 39 (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=284, t.chronic_days=90 | true |
| derived: staging_egfr | max(egfr_early, egfr_late) |
egfr_early=36.1, egfr_late=38.9 | 38.9 |
| derived: both_below_60 | egfr_early < t.g2 and egfr_late < t.g2 |
egfr_early=36.1, egfr_late=38.9, t.g2=60 | true |
| 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=38.9, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15 | G3b |
| 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=True, egfr_early=36.1, egfr_late=38.9, t.g2=60 | false |
| outcome: g1_g2 | staging_egfr >= t.g2 |
staging_egfr=38.9, t.g2=60 | false |
| outcome: g3a | category == 'G3a' |
category=G3b | false |
| outcome: g3b | category == 'G3b' |
category=G3b | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2232); 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-00136 Patient: Amara Holloway To: Dr. Gideon Zeller Clinical indicators from the health record: - Documented in the record: "CKD" [History and physical DOC-000461] - creatinine 1.47 -> eGFR 36 (2025-10-14 09:15) [lab LAB-004642] - creatinine 1.38 -> eGFR 39 (2026-07-25 10:05) [lab LAB-004643] Question: Based on your clinical judgement and the indicators above, can the chronic kidney condition be further specified, including stage if known? Response options (select one or write your own): ( ) Chronic kidney disease stage 3a (eGFR 45-59) ( ) Chronic kidney disease stage 3b (eGFR 30-44) ( ) Chronic kidney disease stage 4 (eGFR 15-29) ( ) 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
- Obesity · Clinical validation gap Documented “class 3 obesity” (E66.813) conflicts with what the criteria support (Obesity, class 1, E66.811).
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2232 | 2026-11-14T20:57:25 | system:llm system |
llm.call |
ENC-00136, ENC-00136.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 4d765629b70b |
| 1406 | 2026-11-14T19:24:31 | system:llm system |
llm.call |
ENC-00136, ENC-00136.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 307b01cf0345 |
| 664 | 2026-11-14T18:29:06 | system:llm system |
llm.call |
ENC-00136, ENC-00136.ckd | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt 23057ac6e924 output bf34b17a9932 entry 890aa19537c8 |