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← Back to the worklist · Whole encounter ENC-00158

Ines Ivers: Acute blood loss anaemia

ENC-00158 · 67M · Cardiology · admitted Thu Nov 05, 2026 09:29 AM · discharged Tue Nov 10, 2026 03:05 PM · attending Dr. Jalen Carrow

Clinical validation gap Criteria met Open

Documented “acute blood loss anemia” (D62) is more specific than the criteria support (Anemia (acute blood-loss criteria not met), D64.9).

Documented vs supported

Documented: “acute blood loss anemia” · D62 Acute posthemorrhagic anemia
Criteria support: Anemia (acute blood-loss criteria not met) · D64.9 Anemia, unspecified
Outcome: Anaemia (nadir 11.1) without an acute fall or transfusion
Rule: Acute blood loss anaemia v2026.11-1
Published source: WHO guideline on haemoglobin cutoffs to define anaemia in individuals and populations (2024), Adult cut-offs: men <13 g/dL, non-pregnant women <12 g/dL (unchanged from 2011) · source (checked 2026-11-14)
Contested: There is no published clinical definition of "acute blood loss anaemia". This rule is a LOCAL CONVENTION: WHO anaemia threshold at the nadir, a documented bleeding source, and an acute fall of >=2 g/dL OR >=2 units transfused (borrowed from the ISTH major-bleeding definition, which secondary restatements word inconsistently as AND/OR).

Effect if the clinician agrees (illustrative)

Change: D62 -> D64.9
Secondary-diagnosis level: CC → non-CC
MS-DRG (illustrative): 292 Heart failure and shock with CC → 293 Heart failure and shock without CC/MCC
Relative weight: 0.8490 → 0.5660 (-0.2830)
Codes before: I50.22, E66.01, R09.02, D62, E11.9, I10, K21.9
Codes after: I50.22, E66.01, R09.02, E11.9, I10, K21.9, D64.9

All open gaps on this encounter together: MS-DRG 292 → 293 (RW -0.2830).

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
Sex	M	sex M · encounter ENC-00158
First haemoglobin this stay (g/dL)	11.5	hemoglobin 11.5 g/dL (first) · lab LAB-005402 · 2026-11-05 10:29
Lowest haemoglobin this stay (g/dL)	11.1	hemoglobin 11.1 g/dL (lowest) · lab LAB-005403 · 2026-11-06 05:00
Highest value before the nadir minus the nadir (g/dL) highest value before the nadir minus the nadir	0.4	hemoglobin 11.5 · lab LAB-005402 · 2026-11-05 10:29 hemoglobin 11.1 · lab LAB-005403 · 2026-11-06 05:00
Red cell units transfused	0	derived (no source row)
A bleeding source quoted from a note, or a bleeding principal diagnosis	True	“bleeding” · History and physical DOC-000531, p. 1, line 7 · quoted span verified Show the quote in the note … admitted with chronic systolic heart failure. Past medical history: heart failure with reduced ejection fraction, type 2 diabetes, hypertension, GERD. Denies bleeding, chest pain or fever. Exam: Lungs: scattered crackles at the bases, no distress. Assessment and plan: 1. Chronic systolic heart failure: diuresis and daily wei …

Rule trace (inputs, thresholds, outcome)

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	hgb_nadir=11.1, sex=M, t.hb_f=12, t.hb_m=13	true
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=0.4, prbc_units=0, t.drop_major=2.0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	acute_fall=False, anaemic=True, bleeding_documented=True	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=True, hgb_drop=0.4, prbc_units=0, t.drop_min=1.0	true

Documentation query

Title and question drafted by model clockworks-mock (audit entry #2266); clinical indicators and answer options assembled by code from the rule and the record.

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DOCUMENTATION QUERY (draft)
Title: Clarification request: hematology documentation
Encounter: ENC-00158   Patient: Ines Ivers   To: Dr. Jalen Carrow

Clinical indicators from the health record:
- Documented in the record: "acute blood loss anemia" [Progress note DOC-000532]
- sex M [encounter ENC-00158]
- hemoglobin 11.5 g/dL (first) (2026-11-05 10:29) [lab LAB-005402]
- hemoglobin 11.1 g/dL (lowest) (2026-11-06 05:00) [lab LAB-005403]
- "bleeding" (2026-11-05 12:29) [History and physical DOC-000531, p. 1, line 7]

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

Response options (select one or write your own):
( ) Acute blood loss anemia: confirmed (please document the supporting clinical information)
( ) Acute blood loss anemia: 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

Heart failure · Specificity gap Documented “chronic systolic heart failure” (I50.22); criteria support the more specific Acute on chronic systolic (HFrEF) heart failure (I50.23).
Obesity · Clinical validation gap Documented “morbid obesity” (E66.01) conflicts with what the criteria support (Obesity, class 1, E66.811).
Acute respiratory failure · Clinical judgement required Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

History

Audit entries for this finding (newest first)
Seq	When (UTC)	Actor	Action	Entities	Decision / reason	Model / hashes
2266	2026-11-14T20:57:26	system:llm system	`llm.call`	ENC-00158, ENC-00158.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 87438843e589 output d57a2be09729 entry fccba4d86d43
1440	2026-11-14T19:24:31	system:llm system	`llm.call`	ENC-00158, ENC-00158.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 87438843e589 output d57a2be09729 entry b6046c8b4a48
698	2026-11-14T18:29:06	system:llm system	`llm.call`	ENC-00158, ENC-00158.blood_loss_anemia	—	clockworks-mock mock-1/exactdx.draft_query@1 prompt 87438843e589 output d57a2be09729 entry ed718166d3de