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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Ximena Kestrel: Hyponatraemia

ENC-00152 · 61M · Cardiology · admitted Sat Nov 07, 2026 08:24 AM · discharged Thu Nov 12, 2026 02:54 PM · attending Dr. Wes Merriweather

Clinical validation gap Criteria not met Open

Documented “hyponatremia” (E87.1) but the criteria are not met: All sodium values 135 or above (lowest 138).

Documented vs supported

Documented: “hyponatremia” · E87.1 Hypo-osmolality and hyponatremia
Criteria support: criteria not met
Outcome: All sodium values 135 or above (lowest 138)
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)

Effect if the clinician agrees (illustrative)

Change: remove E87.1
Secondary-diagnosis level: CC → removed
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: I50.31, E66.811, N18.9, N17.9, E87.1, L89.154
Codes after: I50.31, E66.811, N18.9, N17.9, L89.154

All open gaps on this encounter together: MS-DRG 291 → 291 (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.

Evidence (each item cited to a source row or a quoted span)
Input	Value	Source
Lowest serum sodium this stay (mmol/L)	138.0	sodium 138 mmol/L · lab LAB-005227 · 2026-11-10 05:00
Number of sodium values below 135	0	derived (no source row)

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=138.0, t.low=135, t.moderate=130, t.profound=125	none
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_low_count=0, na_min=138.0, na_treated=False, t.low=135, t.repeat=2	false
outcome: untreated	`na_min < t.low`	na_min=138.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=138.0, t.low=135	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2260); 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-00152   Patient: Ximena Kestrel   To: Dr. Wes Merriweather

Clinical indicators from the health record:
- Documented in the record: "hyponatremia" [Progress note DOC-000516]
- sodium 138 mmol/L (2026-11-10 05:00) [lab LAB-005227]

Question:
The indicators above are documented in this encounter. Could you clarify the status of the documented electrolyte diagnosis?

Response options (select one or write your own):
( ) Hyponatremia: confirmed (please document the supporting clinical information)
( ) Hyponatremia: ruled out
( ) 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 · Clinical validation gap Documented “acute kidney injury” (N17.9) but the criteria are not met: KDIGO creatinine and urine-output criteria not met.
Chronic kidney disease · Specificity gap Documented “CKD” (N18.9); criteria support the more specific Chronic kidney disease stage 4 (N18.4).

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2260	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00152, ENC-00152.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 93e8559a2fcf output b161c13a4bee entry ea4ed410feb5
1434	2026-11-14T19:24:31	system:llm system	`llm.call`	ENC-00152, ENC-00152.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 93e8559a2fcf output b161c13a4bee entry 2b1291faf83a
692	2026-11-14T18:29:06	system:llm system	`llm.call`	ENC-00152, ENC-00152.hyponatremia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 93e8559a2fcf output b161c13a4bee entry 241e4e0fdc2e