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.

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.

Adult malnutrition severity from a dietitian's nutrition assessment (US consensus characteristics, 2012) front_malnutrition_us_consensus@1.0 judgement Cited source; wording is ours Draft · pending review draft — pending clinical and coding review

Status: draft — pending clinical and coding review (draft)
Condition: Malnutrition
Tier: judgement
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.
To confirm: To confirm with a clinician (dietitian reviewer): the social or environmental circumstances levels were entered from memory, not from an opened copy of the consensus.
To confirm with a clinician (dietitian reviewer): the chronic-illness severe intake level. This file has severe as 75% of need or less for 1 month or more and moderate as below 75% for 1 month or more, which differ only at exactly 75%.
To confirm with a clinician: the weight-window tolerance of plus or minus 25% of each period (a local convention for choosing the reference weight).
To confirm with a clinician: grip strength is read as reduced or not reduced; the consensus grades it against norms.
Source checked: not opened: The consensus statement is copyrighted and was not opened in this build; the thresholds were carried from the earlier rule file (rules/malnutrition.yaml) and from the team's entry, some from memory (see the items to confirm). Verify each row against a licensed copy before release.
Use here: front condition (side panel options)
Edition: 2012

Consensus statement: characteristics recommended for the identification and documentation of adult malnutrition

front_malnutrition_us_consensus@1.0

In our words: Applies only when the record holds a dietitian's nutrition assessment. Six characteristics: energy intake, weight loss, fat loss, muscle loss, fluid accumulation and grip strength; at least two are required. Severe: two or more at the severe level. Moderate (non-severe): two or more at the moderate level or worse. The levels depend on the context the dietitian documents (acute illness or injury, chronic illness, or social or environmental circumstances). Example, acute illness, severe: 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. Albumin and prealbumin are not criteria.

Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (White JV et al., J Acad Nutr Diet 2012;112:730-738) (2012) · table of clinical characteristics (cite by title; do not reproduce the table or its layout) · source

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

See also:

VHA Directive 1438, Clinical Nutrition Management and Food and Nutrition Services, Veterans Health Administration (2022), definitions — federal context: defines malnutrition in words only; sets no thresholds
GLIM criteria for the diagnosis of malnutrition, Cederholm T et al. (J Cachexia Sarcopenia Muscle) (2019), Tables 3 and 4 · link — openly licensed alternative definition (front_malnutrition_global_consensus@1.0)

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.