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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.

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

ARDS oxygenation severity by PaO2/FiO2 (Berlin Definition 2012, numeric part only) berlin2012_ards_pf@1.0 1 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 distress syndrome (oxygenation component)
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
alternative beside oxygenation: Superseded by the 2024 global definition; shown only as an alternative beside global2024_ards_intubated_pf.
Edition
Berlin Definition 2012 (2012) (a newer edition exists)
Second source
American Thoracic Society-led global consensus (Am J Respir Crit Care Med 2024;209(1):37-47) 2024 · agrees: Same PaO2/FiO2 bands for intubated patients; the global definition adds SpO2/FiO2 alternatives and a non-intubated category.
Contested
no: The bands are shared by the 2024 global definition for intubated patients.

Acute respiratory distress syndrome: the Berlin Definition

berlin2012_ards_pf@1.0

In our words: Oxygenation bands (PaO2/FiO2, mm Hg): above 200 up to 300 mild; above 100 up to 200 moderate; 100 or less severe. The bands alone never establish the full syndrome.

ARDS Definition Task Force (European Society of Intensive Care Medicine initiative, endorsed by ATS and SCCM) (2012) · Abstract (Europe PMC record of PMID:22797452) · source

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

See also:
  • Acute respiratory distress syndrome: the Berlin definition — review, Critical Care (2013) · link — open-licence restatement (CC BY per Europe PMC metadata only; not verified)

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.

Office blood pressure categories: non-elevated, elevated, hypertension (ESC 2024) esc2024_office_bp@1.0 1 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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
alternative beside blood_pressure: Disagrees with the primary (nhlbi_bp_categories: 130/80 vs 140/90); shown only as 'another published definition gives'.
Edition
2024 (2024)
Second source
National Heart, Lung, and Blood Institute 2025 · disagrees: US categories start hypertension at 130/80; ESC at 140/90. The ESH 2023 guideline could not be opened (HTTP 402).
Contested
yes: Differs from AHA/ACC (hypertension from 130/80; elevated defined by systolic 120-129 only).

2024 ESC Guidelines for the management of elevated blood pressure and hypertension

esc2024_office_bp@1.0

In our words: Office blood pressure (adults, mm Hg): 140/90 or higher is hypertension; systolic 120 to 139 or diastolic 70 to 89 is elevated; below 120/70 is not elevated.

European Society of Cardiology (2024) · Section 5.1, Table 5 (office BP) · source

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

See also:
  • High Blood Pressure: Diagnosis, National Heart, Lung, and Blood Institute (2025) · link — federal primary for blood pressure in this product (nhlbi_bp_categories); differs at 130/80

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, presence only (ESE/ESICM/ERA-EDTA 2014) ese2014_hyponatraemia@1.0 1 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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (sodium)
Edition
2014 (2014) (currency not confirmed)
Second source
National Cancer Institute, Cancer Therapy Evaluation Program (U.S. Department of Health and Human Services) 2025 · partly agrees: CTCAE starts at the laboratory LLN, which is often but not always 135 mmol/L.
Contested
no: The <135 mmol/L definition is widely shared; CTCAE uses the laboratory LLN instead.

Clinical practice guideline on diagnosis and treatment of hyponatraemia

ese2014_hyponatraemia@1.0

In our words: Serum sodium below 135 mmol/L is low.

European Society of Intensive Care Medicine, European Society of Endocrinology and European Renal Association – European Dialysis and Transplant Association (ERBP) (2014) · Abstract · source

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

See also:
  • Laboratory reference interval, the reporting laboratory — no federal or openly licensed source for 135 mmol/L was opened; the laboratory's own range is the recommended alternative

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.

ARDS oxygenation severity in intubated patients by PaO2/FiO2 with PEEP ≥5 (New Global Definition 2024, numeric part only) global2024_ards_intubated_pf@1.0 1 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 distress syndrome (oxygenation component)
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (oxygenation)
Edition
New Global Definition 2024 (2024)
Second source
ARDS Definition Task Force 2012 · agrees: Same bands (the Berlin abstract does not state the PEEP requirement).
Contested
no: Bands unchanged from Berlin for intubated patients.

A New Global Definition of Acute Respiratory Distress Syndrome

global2024_ards_intubated_pf@1.0

In our words: On invasive ventilation with PEEP of at least 5 cm H2O (PaO2:FiO2, mm Hg): above 200 up to 300 mild; above 100 up to 200 moderate; 100 or less severe.

American Thoracic Society-led global consensus (Am J Respir Crit Care Med 2024;209(1):37-47) (2024) · Table 1 'Diagnostic Criteria for the New Global Definition of ARDS', intubated ARDS and footnote ¶ · source

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

See also:
  • Acute respiratory distress syndrome: the Berlin definition, ARDS Definition Task Force (2012) — same bands

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.

COPD airflow obstruction grade by post-bronchodilator spirometry (GOLD 2026) gold2026_copd_airflow@1.0 1 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
Chronic obstructive pulmonary disease (spirometric grade)
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (copd_airflow)
Edition
2026 report (2026)
Second source
none opened · not found: No independent second source (e.g. ATS/ERS) was opened.
Contested
yes: The fixed ratio 0.7 is contested against the lower limit of normal (z-score) approach used by ATS/ERS interpretation standards (not opened); the fixed ratio over-diagnoses in older and under-diagnoses in younger adults.

Global Strategy for Prevention, Diagnosis and Management of COPD: 2026 Report — Pocket Guide

gold2026_copd_airflow@1.0

In our words: When FEV1/FVC after a bronchodilator is below 0.7: FEV1 80% of predicted or more is grade 1; 50 to under 80% grade 2; 30 to under 50% grade 3; under 30% grade 4. A ratio of 0.7 or more shows no obstruction by this fixed ratio.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2026) · Figure 2.10 (PDF page 20); key points (PDF page 11) · 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 the Management of COPD, VA and DoD (2026) · link — federal; recommends post-bronchodilator spirometry but its summary gives no numeric ratio

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.

Serum 25(OH)D reference levels for bone health (Institute of Medicine 2011) iom2011_vitamin_d@1.0 1 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 D status
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
not run by default: The source explicitly declined to define deficiency; not run by default.
Edition
2011 dietary reference intakes (2011) (currency not confirmed)
Second source
Endocrine Society 2011 · partly agrees: Both use 20 ng/mL (50 nmol/L) as a boundary; the Endocrine Society calls 21-29 ng/mL insufficient, which the IOM does not.
Contested
yes: See es2011_vitamin_d: bodies disagree; the IOM explicitly declined to set a deficiency cut-point.

The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know

iom2011_vitamin_d@1.0

In our words: Serum 25(OH)D: below 16 ng/mL (40 nmol/L) is under the level that meets about half the population's needs; 16 to under 20 ng/mL is under the level that meets nearly everyone's needs; 20 to 50 ng/mL meets nearly everyone's needs; above 50 ng/mL (125 nmol/L) may carry a risk of harm.

Institute of Medicine committee (J Clin Endocrinol Metab 2011;96:53-58, doi:10.1210/jc.2010-2704) (2011) · Section 'Serum 25OHD Levels and Screening' · source

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

See also:
  • Vitamin D fact sheet for health professionals, NIH Office of Dietary Supplements · link — federal restatement; not verified (HTTP 403 on 2026-11-14)

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.

Serum lactate above the Sepsis-3 septic-shock threshold (numeric component only) sepsis3_septic_shock_lactate@1.0 1 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
Septic shock (lactate component)
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (lactate)
Edition
Sepsis-3 (2016) (2016)
Second source
none opened · not found: No independent second source was opened for this threshold.
Contested
no: The CMS SEP-1 measure and the Surviving Sepsis Campaign use lactate thresholds for other purposes (for example ≥4 mmol/L); those documents were not opened for this entry.

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

sepsis3_septic_shock_lactate@1.0

In our words: A lactate above 2 mmol/L (18 mg/dL) is the lactate part of the septic-shock criteria; it never establishes septic shock on its own.

Society of Critical Care Medicine and European Society of Intensive Care Medicine 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, optional lactate criterion · link — federal, surveillance only: lactate 2.0 mmol/L or more (not above 2); not merged with this entry; opened by the resourcing review, not re-opened in this build

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.

Hyperkalaemia and its severity (UK Kidney Association, July 2026 update) ukka2026_hyperkalaemia@1.0 1 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
Hyperkalaemia
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (potassium)
Edition
updated July 2026 (2026)
Second source
National Cancer Institute, Cancer Therapy Evaluation Program (U.S. Department of Health and Human Services) 2025 · disagrees: CTCAE uses different bands; the UKKA text states its 5.5 mmol/L threshold comes from the European Resuscitation Council guideline, which was not opened.
Contested
yes: The guideline itself says that no definition of hyperkalaemia is universally accepted; it adopts the ERC threshold of 5.5 mmol/L. CTCAE grades differ (see ctcae6_hyperkalaemia).

Clinical Practice Guidelines: Treatment of Acute Hyperkalaemia in Adults

ukka2026_hyperkalaemia@1.0

In our words: Serum potassium (adults): 5.5 to 5.9 mmol/L mild; 6.0 to 6.4 moderate; 6.5 or higher severe.

UK Kidney Association (2026) · Introduction, document page 9 (PDF page 10) · source

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

See also:
  • Laboratory reference interval, the reporting laboratory — no federal potassium definition was opened; the laboratory's own range is the recommended alternative

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.

Osteoporosis and osteopenia by BMD T-score (WHO 1994) who1994_osteoporosis@1.0 1 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
Osteoporosis / osteopenia
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (bone_density)
Edition
WHO Technical Report Series 843 (1994) (1994) (currency not confirmed)
Second source
none opened · not found: ISCD official positions and national guidelines that restate the categories were not opened.
Contested
yes: T-score categories were defined for postmenopausal (white) women; their use in men and other populations relies on later bodies (e.g. ISCD), which were not opened; the report itself calls cut-off values 'somewhat arbitrary'.

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO Study Group (WHO Technical Report Series 843)

who1994_osteoporosis@1.0

In our words: Bone density T-score (postmenopausal women): -1 or higher normal; between -1 and -2.5 low bone mass; -2.5 or lower osteoporosis; below -2.5 with a fragility fracture severe osteoporosis.

World Health Organization (1994) · Section 2.1 Definitions, printed pages 5-6 (PDF pages 11-12) · source

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

See also:
  • NIH restatement of the T-score categories, National Institutes of Health — not verified (pages returned 403 or did not resolve)

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.

Iron deficiency by serum ferritin (WHO 2020) who2020_iron_deficiency_ferritin@1.0 1 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
Iron 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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (ferritin)
Edition
2020 (2020)
Second source
none opened · not found: No independent source with the same cut-offs was opened.
Contested
yes: Ferritin cut-offs for iron deficiency vary widely between bodies and studies (the guideline's own review cites thresholds from <12 to <30 µg/L in pregnancy); WHO's are low (high specificity). Other bodies (e.g. gastroenterology guidance) use higher values; those texts were not opened.

WHO guideline on use of ferritin concentrations to assess iron status in individuals and populations

who2020_iron_deficiency_ferritin@1.0

In our words: Ferritin suggesting iron deficiency: below 15 µg/L at 5 years and older (healthy) and in first-trimester pregnancy; below 12 µg/L under 5 years (healthy); below 30 µg/L under 5 with infection or inflammation; below 70 µg/L at 5 and older with infection or inflammation.

World Health Organization (2020) · Executive summary, recommendations 1.1-1.2 (PDF page 11) and Table 1 (PDF page 12) · 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.

Anaemia and its severity by haemoglobin (WHO 2024) who2024_anaemia@1.0 1 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
Anaemia
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
opened on 2026-11-14: Opened by the build that encoded this entry; the threshold matches the opened text.
Use here
default set (haemoglobin)
Edition
2024 (2024)
Second source
National Cancer Institute, Cancer Therapy Evaluation Program (U.S. Department of Health and Human Services) 2025 · partly agrees: CTCAE v6.0 also uses 80 g/L as a severity boundary (grade 3 <80 g/L, WHO severe <80 g/L for adults) but defines the start of anaemia by the laboratory LLN, not fixed WHO cut-offs. No independent source repeating the WHO 2024 table was opened.
Contested
yes: Cut-offs are 5th percentiles of mostly higher-income populations (WHO's own remark); the men's 130 g/L cut-off and severity percentages were debated by the guideline group; CTCAE and laboratory reference ranges use other limits; older adults (>65) are not covered.

Guideline on haemoglobin cutoffs to define anaemia in individuals and populations

who2024_anaemia@1.0

In our words: Haemoglobin, adults 15 to 65, adjusted for altitude and smoking: anaemia below 130 g/L in men and below 120 g/L in non-pregnant women; moderate below 110 g/L; severe below 80 g/L. Pregnancy by trimester and children have their own cut-offs.

World Health Organization (2024) · Executive summary: Table 2 (PDF page 12), Table 3 (PDF page 13), Table 4 (PDF page 14), Table 5 (PDF page 15) · source

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

See also:
  • Anemia: Diagnosis, National Heart, Lung, and Blood Institute (2025) — federal page gives normal ranges only (men 14 to 17 g/dL, women 12 to 15 g/dL), not anaemia cut-offs
  • Laboratory reference interval, the reporting laboratory — shown beside the WHO cut-offs where the laboratory sends one

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.

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.

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.