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DataCrafters synthetic data · demonstration

Staff surface Definitions and reviews

Definition library

Every executable definition, side-panel definition and catalogue entry, in three groups by the licence of its source, with its threshold in our own words and the source it is cited to. All are drafts pending review; a definition shows as reviewed only when both a clinical and a coding approval are recorded. Default set library_default_set@1.1.

Local criteria: site choices among published definitions and named local variants of the side-panel definitions, each with a change record, two approvals and an outcome preview.

Coder worklist

Extended capabilities (licence required before commercial use)

These entries rest on sources that are not freely licensed: copyrighted guidelines and consensus statements, cited fact-only, and anything else that would need a licence or permission. They are kept here, apart from the core definitions, to show the product's full reach. Each threshold is restated in our own words with the source cited by title, body and year; no copyrighted text, table or figure is reproduced. Before commercial release each would be licensed from its publisher or re-sourced to a freely usable source.

11 executable, 1 side-panel, 14 catalogue. Every entry here: licence or permission to be obtained before commercial use.

Setting: show extended capabilities on clinician screens

Current on clinician screens: Off (default) When on, findings from extended definitions appear on the side panel and the per-note screen under their own heading, after the core findings. Off or on, every check runs and replays the same, and the coder view shows both groups. The guided demo's four cases are unaffected.

CDI or coding staff can change this setting: switch the demo user.

Licence status

Thresholds are stated in our own words. Verbatim text is kept only from U.S. government works and openly licensed (CC BY) sources, with the attribution the licence asks for; copyrighted guidelines are cited by title, body and year, with a locator. No endorsement by the cited bodies is implied. This is not legal advice: counsel should review before commercial release.

Cancer-treatment adverse-event grading scale (NCI CTCAE): off by default

CTCAE grades describe adverse events in people receiving cancer treatment, usually in trials; they are not diagnostic criteria, and several grades depend on the laboratory reference range or on clinical descriptors that are not encoded. Using them outside that setting is a local decision for the clinical reviewer.

Current: Off (default) When on, grading entries are shown only as "another published definition gives …" or as values needing clinical judgement; they never raise a "not stated" item.

CDI or coding staff can change this setting. A clinician account records clinical reviews; a coding or documentation account records coding reviews: switch the demo user.

14 of 26 in “Extended capabilities” shown · open an entry for its source, threshold and review.

Acute respiratory failure acute_respiratory_failure catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Acute respiratory failure
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: no authoritative numeric definition of acute respiratory failure was opened, so no blood-gas threshold is recorded. The diagnosis also rests on work of breathing and clinical context.

Source not opened

acute_respiratory_failure

In our words: No measurement-only definition is stored; oxygenation bands are in the two ARDS entries.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Hyperosmolar hyperglycaemic state ada2024_hhs catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
HHS
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
catalogue (not executable)
Edition
2024
Why not executable
Part of the 2024 hyperglycaemic crises consensus (see ada2024_hyperglycaemic_crises): the diagnostic figure was not readable in the opened text. The text requires all four components and defines HHS as without acidosis (pH 7.3 or higher and bicarbonate 18 mmol/L or higher). Not executable until the figure is opened.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

ada2024_hhs

In our words: Hyperosmolar state: no acidosis (pH 7.3 or higher and bicarbonate 18 mmol/L or higher); glucose and osmolality cut-offs not verified.

ADA, EASD, JBDS, AACE and DTS (Diabetes Care 2024;47:1257-1275) (2024) · Section 4 · source

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Diabetic ketoacidosis and hyperosmolar hyperglycaemic state (ADA/EASD/JBDS/AACE/DTS consensus 2024) ada2024_hyperglycaemic_crises catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
DKA / HHS
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
catalogue (not executable)
Edition
2024
Why not executable
The diagnostic criteria are in the consensus report's Figure 2, which was not readable in the opened text; the severity table (Table 2) does not require every variable and includes mental status, and its bicarbonate bands overlap at 15 mmol/L (mild 15–18, moderate 10 to <15). Not executable until Figure 2 is opened and the overlaps are resolved by a clinician.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

ada2024_hyperglycaemic_crises

In our words: Severity: β-hydroxybutyrate 3.0 to 6.0 mmol/L mild or moderate, above 6.0 severe; pH above 7.25 to below 7.30 mild, 7.0 to 7.25 moderate, below 7.0 severe; bicarbonate 15 to 18 mild, 10 to below 15 moderate, below 10 mmol/L severe.

ADA, EASD, JBDS, AACE and DTS (Diabetes Care 2024;47:1257-1275, doi:10.2337/dci24-0032) (2024) · Table 2 'DKA classification and suggested level of care by severity' · source

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

2025 AHA/ACC blood pressure categories table (guideline text itself) aha2025_bp_table catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Hypertension
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: the guideline (Hypertension 2025;82:e212-e316; Circulation 2025;152:e114-e218) and the AHA patient page refused automated access (HTTP 403). The same categories are executable from the NHLBI page (nhlbi_bp_categories), with the 130/80 threshold confirmed by an open-access commentary.

Source not opened

aha2025_bp_table

In our words: Same categories as the federal NHLBI page (see nhlbi_bp_categories); nothing stored from the guideline.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Malnutrition characteristics used in US hospitals (Academy/ASPEN 2012 consensus) aspen_academy2012_malnutrition catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Malnutrition
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: Not opened in this build; numbers carried from apps/exactdx/rules/malnutrition.yaml (encoded there from the Academy's table, verified_on 2026-11-14). Keep out of any default set until reviewed.
Use here
catalogue (not executable)
Edition
2012
Why not executable
Source not opened in this build, and no permissive source exists: the consensus is copyrighted. Severity needs at least two of six characteristics in an acute-illness or chronic-illness context, and fat loss, muscle loss, fluid and grip strength are examination findings. Numbers are carried, in our own words, from apps/exactdx/rules/malnutrition.yaml; the table and its layout are not reproduced.

Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition

aspen_academy2012_malnutrition

In our words: Severe malnutrition, acute illness: at least two of intake at or below half of need for 5 days or more; weight loss over 2% in a week, over 5% in a month or over 7.5% in 3 months; moderate fat or muscle loss; moderate to severe fluid; reduced grip.

White JV, Guenter P, Jensen G, Malone A, Schofield M (J Acad Nutr Diet 2012;112:730-738; JPEN 2012, doi:10.1177/0148607112440285) (2012) · Table of clinical characteristics

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

See also:
  • GLIM criteria for the diagnosis of malnutrition, GLIM (J Cachexia Sarcopenia Muscle 2019) (2019) · link — open-licence alternative (glim2019_malnutrition)
  • VHA Directive 1438(1), Clinical Nutrition Management, Veterans Health Administration (2022) — federal; defines malnutrition in words only, no thresholds
  • CMS986 Malnutrition Care Score, CMS / Academy of Nutrition and Dietetics (2026) — copyrighted quality measure; context only

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Encephalopathy (metabolic, toxic, septic) encephalopathy catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Encephalopathy
Tier
3
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Encephalopathy is diagnosed clinically (altered mental status with a cause); no measurement-based definition from an authoritative body was opened. Source not opened.

Source not opened

encephalopathy

In our words: Diagnosed clinically; no measurement-only definition is stored.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Hyponatraemia severity and timing (ESE/ESICM/ERA-EDTA 2014) ese2014_hyponatraemia_severity catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Hyponatraemia
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: the guideline's severity bands (mild, moderate, profound) and acute/chronic classification are in the full text, which could not be opened (publisher pages refused or returned server errors; not open access in Europe PMC). Only the <135 mmol/L definition from the abstract is executable (ese2014_hyponatraemia).

Source not opened

ese2014_hyponatraemia_severity

In our words: Severity bands not opened; only the below-135 mmol/L definition is executable.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Hypertension grades 1-3 (ESH 2023) esh2023_bp_grades catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Hypertension
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: the 2023 ESH guideline (J Hypertens 2023;41:1874) returned HTTP 402 (payment required). Not encoded; ESC 2024 office categories are executable as esc2024_office_bp.

Source not opened

esh2023_bp_grades

In our words: Not opened (payment required); nothing stored.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Myocardial infarction (Fourth Universal Definition, 2018) fourth_udmi2018_myocardial_infarction catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Myocardial infarction
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
2018
Why not executable
Source not opened: only the citation record was found (no abstract or full text readable on 2026-11-14). Myocardial infarction definitions combine biomarker results with clinical evidence of ischaemia, which numbers alone cannot decide; no threshold is recorded here.

Fourth Universal Definition of Myocardial Infarction (2018)

fourth_udmi2018_myocardial_infarction

In our words: Combines biomarker results with clinical evidence; no threshold stored.

ESC/ACC/AHA/WHF joint task force (J Am Coll Cardiol 2018;72:2231-2264) (2018) · citation record only (Europe PMC, PMID:30153967); full text not opened · source

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Hypoxaemia by SpO2 or PaO2 hypoxaemia_spo2_pao2 catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Hypoxaemia
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: no oxygen-therapy guideline defining hypoxaemia by SpO2 or PaO2 was opened. PaO2/FiO2 bands are executable within the ARDS definitions.

Source not opened

hypoxaemia_spo2_pao2

In our words: No oxygen-saturation definition opened; nothing stored.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Pressure injury staging (NPIAP 2016) npiap2016_pressure_injury_stages catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Pressure injury
Tier
3
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
catalogue (not executable)
Edition
2016
Why not executable
Stages are defined by what the wound looks like on examination (intact skin with non-blanchable erythema, partial-thickness loss, full-thickness loss, exposed fascia or bone, slough or eschar obscuring the base, deep tissue injury). There is no measurement to compute.

Pressure Injury and Stages (staging illustrations and definitions)

npiap2016_pressure_injury_stages

In our words: Stages are judged by looking at the wound (from intact skin with redness that does not blanch to full-thickness loss); there is no measurement.

National Pressure Injury Advisory Panel (2016) · NPIAP sheet 'Pressure Injury and Stages' (© September 2016), Stage 1 definition; the NPIAP staging web page refused automated access (HTTP 403) on 2026-11-14, so the deep link could not be confirmed · source

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

See also:
  • VA/DoD Clinical Practice Guideline for Pressure Injury, VA and DoD (2026) — recommended federal primary; not opened in this build (re-sourcing open)

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Sepsis and septic shock (Sepsis-3) sepsis3_sepsis_and_septic_shock catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Sepsis / septic shock
Tier
2
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
catalogue (not executable)
Edition
2016
Why not executable
Sepsis needs suspected or documented infection and an acute change in total SOFA score of 2 points or more consequent to the infection; septic shock adds vasopressor-dependent hypotension and lactate >2 mmol/L after adequate volume resuscitation. Infection, attribution and adequacy of resuscitation are clinical judgements; SOFA needs six organ systems including the Glasgow Coma Scale.

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

sepsis3_sepsis_and_septic_shock

In our words: Sepsis: suspected infection with a rise of 2 or more SOFA points. Septic shock adds vasopressors to keep mean pressure at 65 mm Hg or more and lactate above 2 mmol/L after fluids.

SCCM and ESICM task force (JAMA 2016;315:801-810) (2016) · Box 3 'New Terms and Definitions' · source

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

See also:
  • Hospital Toolkit for Adult Sepsis Surveillance, Centers for Disease Control and Prevention (2018), Adult Sepsis Event · link — federal surveillance definition (not diagnostic); optional lactate 2.0 mmol/L or more

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

Vitamin B12 deficiency vitamin_b12_deficiency catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Vitamin B12 deficiency
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: no guideline stating serum cobalamin cut-offs was opened (thresholds are assay-dependent and contested; methylmalonic acid and holotranscobalamin are often needed). Not encoded.

Source not opened

vitamin_b12_deficiency

In our words: No cobalamin cut-off opened; nothing stored.

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.

BMI action points for Asian populations (WHO expert consultation 2004) who2004_asian_bmi catalogue Cited source; wording is ours Draft · pending review draft — pending clinical and coding review
Status
draft — pending clinical and coding review (draft — requires clinical and coding review)
Condition
Obesity / overweight
Tier
1
Licence
Cited source; wording is ours
Commercial use
Licence or permission to be obtained before commercial use. Thresholds restated in our own words; source cited; no text reproduced.
Source checked
not opened: No source was opened; nothing is quoted or encoded.
Use here
catalogue (not executable)
Edition
Why not executable
Source not opened: the WHO expert consultation (Lancet 2004;363:157-163) was not opened; population-specific BMI cut-offs are therefore not encoded.

Source not opened

who2004_asian_bmi

In our words: Lower BMI action points for Asian populations were not opened; nothing stored (WHO non-commercial licence if ever encoded).

cited source; wording is ours (numbers restated, no text reproduced). No endorsement by the cited bodies is implied.

Review

Reviewed only when both a clinical review and a coding review are recorded as approved.

Clinical review: none recorded yet.

Coding review: none recorded yet.