P02 KE-P02 · outpatient visit

One row per condition family: what the record supports under the published definition, what the note states, the visit's diagnosis entries, and an assessment. Codes are coded from the signed documentation; the software never assigns one.

Note: unsigned draft

Side-panel conditions check FRUN-00002 · front-engine 1.2 · replay af1499b75cee726e…

Library check LRUN-00002 · library_default_set@1.1 · library-engine 1.1 · replay 9869a67f94f6e989… · Data (JSON)

Core definitions 2

Core definitions: condition families for this encounter (2)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Kidney disease stage (filtering rate) measured · side-panel condition	`front_kidney_stage_wording@1.0` Draft · pending review No wording's requirement is met by the record Urine albumin-to-creatinine ratio 12 mg/g on 2026-05-16: A1 range · L-0004 Albuminuria on two tests at least 90 days apart: not shown Options and what the record shows Chronic kidney disease stage 1 · needs filtering rate 90 or above with a kidney damage marker (for example albuminuria on two tests at least 90 days apart) · record: filtering rate 60 or above; needs a kidney damage marker (no persistent albuminuria on file) · not assessable Chronic kidney disease stage 2 · needs filtering rate 60-89 with a kidney damage marker (for example albuminuria on two tests at least 90 days apart) · record: filtering rate 60 or above; needs a kidney damage marker (no persistent albuminuria on file) · not assessable Chronic kidney disease stage 3a · needs filtering rate 45-59 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met Chronic kidney disease stage 3b · needs filtering rate 30-44 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met Chronic kidney disease stage 4 · needs filtering rate 15-29 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met Chronic kidney disease stage 5 · needs filtering rate below 15 on two results at least 90 days apart · record: results at least 90 days apart are 60 or above · not met Citation Kidney disease stage wording by filtering rate, with the albumin-to-creatinine category (options for the clinician) front_kidney_stage_wording@1.0 In our words: Kidney disease by filtering rate: below 60 on results at least 3 months apart; or urine albumin-to-creatinine ratio 30 mg/g or higher on two tests at least 3 months apart. Stage by filtering rate: G1 90 or above; G2 60-89; G3a 45-59; G3b 30-44; G4 15-29; G5 below 15 (G1 and G2 also need a marker of kidney damage). Albumin-to-creatinine category: A1 below 30, A2 30-299, A3 300 mg/g or above. The filtering rate is estimated with the 2021 race-free creatinine equation. Decreased eGFR <60 mL/min/1.73 m2 (GFR categories G3a-G5) for ≥3 months Department of Veterans Affairs and Department of Defense, VA/DoD Clinical Practice Guideline for the Primary Care Management of Chronic Kidney Disease, Provider Summary (Version 5.0) (2025) · Sidebar 6 'Criteria for CKD' (PDF page 16; printed page 13 of 37). Do not use Sidebar 9 (a reproduced third-party figure) · source Licence: U.S. government work (public domain); filtering-rate stage bands (90, 60, 45, 30, 15) and the G3a/G3b split: fact only citation; albumin-to-creatinine categories (A1 below 30, A2 30-299, A3 300 mg/g or above): fact only citation; 2021 creatinine equation: public domain. Source checked: opened. No endorsement by the cited bodies is implied. To confirm with a clinician: three months is encoded as 90 days (the VA/DoD summary says 3 months or more).	Not stated	None entered	Nothing to act on Kidney results 180 days apart are 60 or above (filtering rate 87.5 on 2026-05-16 and 87.5 on 2026-11-12) and the note doesn't mention kidney function. Clinician's response to the side-panel card: No response yet
Whole code category, for reference (no code is selected, ranked or suggested): Kidney disease stage (filtering rate) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `N18` Chronic kidney disease (CKD) (9 codes in the category). `N18.1` Chronic kidney disease, stage 1 `N18.2` Chronic kidney disease, stage 2 (mild) `N18.30` Chronic kidney disease, stage 3 unspecified `N18.31` Chronic kidney disease, stage 3a `N18.32` Chronic kidney disease, stage 3b `N18.4` Chronic kidney disease, stage 4 (severe) `N18.5` Chronic kidney disease, stage 5 `N18.6` End stage renal disease `N18.9` Chronic kidney disease, unspecified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).
Obesity / overweight / underweight (body-mass index) measured	`cdc_adult_bmi@1.0` Draft · pending review Criteria not met: Healthy weight: 18.5 to less than 25 bmi 24 kg/m2 2026-11-12 11:05 · LM-P02-01 Window: 365 days before the check. Citation Adult BMI categories: underweight, healthy weight, overweight, obesity classes 1-3 (CDC) cdc_adult_bmi@1.0 In our words: Adult body-mass index: under 18.5 underweight; 18.5 to under 25 healthy; 25 to under 30 overweight; 30 to under 35 obesity class 1; 35 to under 40 class 2; 40 or higher class 3. Underweight: Less than 18.5; Healthy Weight: 18.5 to less than 25; Overweight: 25 to less than 30; Obesity: 30 or greater; Class 1 Obesity: 30 to less than 35; Class 2 Obesity: 35 to less than 40; Class 3 Obesity (Severe Obesity): 40 or greater Centers for Disease Control and Prevention, Adult BMI Categories (2024) · Adult BMI categories table · source Licence: U.S. government work (public domain). Source checked: opened. No endorsement by the cited bodies is implied. Contested: BMI cut-offs are population-specific (WHO 2004 expert consultation proposed lower action points for Asian populations; not opened) and BMI does not measure adiposity directly; the CDC page applies the categories 'regardless of age, sex, or race' for adults. Not encoded: The CDC page states no exception for pregnancy, athletes or ethnicity; population-specific cut-offs (for example lower thresholds proposed for Asian populations) are not encoded. BMI is a screening measure (CDC); obesity as a disease (for example the 2025 Lancet Commission 'clinical obesity') needs other assessment. BMI is taken as recorded; it is not computed from weight and height.	Not stated	`E66.9` Obesity, unspecified (visit diagnosis list (synthetic))	Entered or stated without support in the record Draft a query
Whole code category, for reference (no code is selected, ranked or suggested): Obesity / overweight / underweight (body-mass index) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E66` Overweight and obesity: distinguishes overweight (E66.3), obesity class 1/2/3 (E66.811-E66.813), morbid obesity due to excess calories or with alveolar hypoventilation, drug-induced, other, unspecified (10 codes in the category). `E66.01` Morbid (severe) obesity due to excess calories `E66.09` Other obesity due to excess calories `E66.1` Drug-induced obesity `E66.2` Morbid (severe) obesity with alveolar hypoventilation `E66.3` Overweight `E66.811` Obesity, class 1 `E66.812` Obesity, class 2 `E66.813` Obesity, class 3 `E66.89` Other obesity not elsewhere classified `E66.9` Obesity, unspecified `Z68` Body mass index [BMI]: distinguishes BMI value bands for adults (Z68.1-Z68.45) and percentile bands for paediatrics (Z68.5-) (33 codes in the category). `Z68.18` Body mass index [BMI] 18.4 or less, adult `Z68.19` Body mass index [BMI] 18.5-19.9, adult `Z68.20` Body mass index [BMI] 20.0-20.9, adult `Z68.21` Body mass index [BMI] 21.0-21.9, adult `Z68.22` Body mass index [BMI] 22.0-22.9, adult `Z68.23` Body mass index [BMI] 23.0-23.9, adult `Z68.24` Body mass index [BMI] 24.0-24.9, adult `Z68.25` Body mass index [BMI] 25.0-25.9, adult `Z68.26` Body mass index [BMI] 26.0-26.9, adult `Z68.27` Body mass index [BMI] 27.0-27.9, adult `Z68.28` Body mass index [BMI] 28.0-28.9, adult `Z68.29` Body mass index [BMI] 29.0-29.9, adult `Z68.30` Body mass index [BMI] 30.0-30.9, adult `Z68.31` Body mass index [BMI] 31.0-31.9, adult `Z68.32` Body mass index [BMI] 32.0-32.9, adult `Z68.33` Body mass index [BMI] 33.0-33.9, adult `Z68.34` Body mass index [BMI] 34.0-34.9, adult `Z68.35` Body mass index [BMI] 35.0-35.9, adult `Z68.36` Body mass index [BMI] 36.0-36.9, adult `Z68.37` Body mass index [BMI] 37.0-37.9, adult `Z68.38` Body mass index [BMI] 38.0-38.9, adult `Z68.39` Body mass index [BMI] 39.0-39.9, adult `Z68.41` Body mass index [BMI] 40.0-44.9, adult `Z68.42` Body mass index [BMI] 45.0-49.9, adult `Z68.43` Body mass index [BMI] 50.0-59.9, adult `Z68.44` Body mass index [BMI] 60.0-69.9, adult `Z68.45` Body mass index [BMI] 70 or greater, adult `Z68.51` Body mass index [BMI] pediatric, less than 5th percentile for age `Z68.52` Body mass index [BMI] pediatric, 5th percentile to less than 85th percentile for age `Z68.53` Body mass index [BMI] pediatric, 85th percentile to less than 95th percentile for age `Z68.54` Body mass index [BMI] pediatric, 95th percentile for age to less than 120% of the 95th percentile for age `Z68.55` Body mass index [BMI] pediatric, 120% of the 95th percentile for age to less than 140% of the 95th percentile for age `Z68.56` Body mass index [BMI] pediatric, greater than or equal to 140% of the 95th percentile for age `R63` Symptoms and signs concerning food and fluid intake: distinguishes R63.6 underweight (one code) (11 codes in the category). `R63.0` Anorexia `R63.1` Polydipsia `R63.2` Polyphagia `R63.30` Feeding difficulties, unspecified `R63.31` Pediatric feeding disorder, acute `R63.32` Pediatric feeding disorder, chronic `R63.39` Other feeding difficulties `R63.4` Abnormal weight loss `R63.5` Abnormal weight gain `R63.6` Underweight `R63.8` Other symptoms and signs concerning food and fluid intake Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).

Extended capabilities (licence required before commercial use) 1

Extended capabilities: published criteria cited by title and restated in our own words, no text reproduced; a licence or permission is needed before commercial use. Shown to coders always; on clinician screens only when the setting is on (now off).

Extended capabilities (licence required before commercial use): condition families for this encounter (1)
Condition family	What the record supports	What the note states	Visit diagnosis entries	Assessment
Anaemia measured	`who2024_anaemia@1.0` Draft · pending review Not assessable: needed to choose the population-specific thresholds: context 'pregnant' not provided; needed to choose the population-specific thresholds: context 'trimester' not provided haemoglobin 128 g/L 2026-11-12 11:00 · LM-P02-04 Window: 30 days before the check. Citation Anaemia and its severity by haemoglobin (WHO 2024) 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, Guideline on haemoglobin cutoffs to define anaemia in individuals and populations (2024) · Executive summary: Table 2 (PDF page 12), Table 3 (PDF page 13), Table 4 (PDF page 14), Table 5 (PDF page 15) · source Licence: cited source; wording is ours (numbers restated, no text reproduced). Source checked: opened. No endorsement by the cited bodies is implied. Contested: 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. Not encoded: The elevation formula (0.0056384 x elevation + 0.0000003 x elevation²) is not used; the 500 m table rows are. The remark that tailored adjustments may be warranted above 2500 m is not encoded. Adjustment for inflammation/infection (malaria) and for genetic ancestry: WHO recommends none (normative statements 2.b and 2.c); nothing is applied. Type and cause of anaemia (iron deficiency, blood loss, haemolysis) are not assessed. Persons older than 65 years and infants under 6 months: Table 2 gives no cut-off, so they are not assessable. Exactly 20 cigarettes per day: Table 5 lists '10–19' and '>20', so 20 per day is outside the table and not assessable (source gap).	Not stated	None entered	Cannot be assessed context
Whole code category, for reference (no code is selected, ranked or suggested): Anaemia Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `D64` Other anemias: distinguishes type of anaemia (sideroblastic, congenital dyserythropoietic, due to antineoplastic chemotherapy, other specified, unspecified) (8 codes in the category). `D64.0` Hereditary sideroblastic anemia `D64.1` Secondary sideroblastic anemia due to disease `D64.2` Secondary sideroblastic anemia due to drugs and toxins `D64.3` Other sideroblastic anemias `D64.4` Congenital dyserythropoietic anemia `D64.81` Anemia due to antineoplastic chemotherapy `D64.89` Other specified anemias `D64.9` Anemia, unspecified `D50` Iron deficiency anemia: distinguishes iron deficiency anaemia: secondary to chronic blood loss, sideropenic dysphagia, other, unspecified (4 codes in the category). `D50.0` Iron deficiency anemia secondary to blood loss (chronic) `D50.1` Sideropenic dysphagia `D50.8` Other iron deficiency anemias `D50.9` Iron deficiency anemia, unspecified `D62` Acute posthemorrhagic anemia: distinguishes acute posthaemorrhagic anaemia (single code) (1 codes in the category). `D62` Acute posthemorrhagic anemia Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).