P04 KE-P04 · 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-00004 · front-engine 1.2 · replay 4d5305c5258cba95…

Library check LRUN-00004 · library_default_set@1.1 · library-engine 1.1 · replay 58a09a7192d11239… · Data (JSON)

Core definitions 1

Core definitions: condition families for this encounter (1)
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 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 220 days apart are 60 or above (filtering rate 72.7 on 2026-04-04 and 77.9 on 2026-11-10) 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).

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
Osteoporosis / osteopenia (bone density) measured	`who1994_osteoporosis@1.0` Draft · pending review Osteoporosis: 2.5 SD or more below the young adult mean bmd t score -2.7 SD 2026-10-11 09:00 · LM-P04-01 Window: 1095 days before the check. Citation Osteoporosis and osteopenia by BMD T-score (WHO 1994) 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, Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO Study Group (WHO Technical Report Series 843) (1994) · Section 2.1 Definitions, printed pages 5-6 (PDF pages 11-12) · source Licence: cited source; wording is ours (numbers restated, no text reproduced). Source checked: opened. No endorsement by the cited bodies is implied. Contested: 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'. Not encoded: Men, premenopausal women and children: the report states the categories for women; not assessable. The site, technique, equipment and reference population (the report notes that results differ by measurement site and technique) are not checked; the lowest T-score passed is used. Fracture risk (e.g. FRAX) is not assessed.	Osteopenia	None entered	Supported, but entered or stated less specifically than the record supports the category written in the note differs from the one the values meet Draft a query
Whole code category, for reference (no code is selected, ranked or suggested): Osteoporosis / osteopenia (bone density) Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `M81` Osteoporosis without current pathological fracture: distinguishes osteoporosis without current pathological fracture: age-related, localized, other (3 codes in the category). `M81.0` Age-related osteoporosis without current pathological fracture `M81.6` Localized osteoporosis [Lequesne] `M81.8` Other osteoporosis without current pathological fracture `M80` Osteoporosis with current pathological fracture: distinguishes osteoporosis with current pathological fracture, by type, site and laterality, with encounter and healing 7th characters (324 codes in the category). 324 codes; see the official files `M85` Other disorders of bone density and structure: distinguishes M85.8- other specified disorders of bone density and structure (used for osteopenia), by site and laterality (169 codes in the category). 169 codes; see the official files Codes in this family for the category the record supports: `M81.0` Age-related osteoporosis without current pathological fracture; `M81.6` Localized osteoporosis [Lequesne]; `M81.8` Other osteoporosis without current pathological fracture. Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).