P22 KE-P22 · 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-00022 · front-engine 1.2 · replay 822f7d5c71dd51c0…

Library check LRUN-00022 · library_default_set@1.1 · library-engine 1.1 · replay aa96b8876c378683… · 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 (not assessable) 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: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · 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: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · not assessable Chronic kidney disease stage 3a · needs filtering rate 45-59 on two results at least 90 days apart · record: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · not assessable Chronic kidney disease stage 3b · needs filtering rate 30-44 on two results at least 90 days apart · record: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · not assessable Chronic kidney disease stage 4 · needs filtering rate 15-29 on two results at least 90 days apart · record: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · not assessable Chronic kidney disease stage 5 · needs filtering rate below 15 on two results at least 90 days apart · record: kidney transplant on record (procedure history, since 2021-05-20): staging and acute change in a transplanted kidney follow transplant-specific assessment · not assessable 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	Cannot be assessed Could not check kidney function: kidney transplant is on record, and the filtering-rate equation is not reliable then. Clinician's response to the side-panel card: No response yet · offer OF-000018
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).
Hypertension measured	`nhlbi_bp_categories@1.0` Draft · pending review Not assessable: no reading with all of bp_systolic_office, bp_diastolic_office recorded at the same time; no usable bp_diastolic_office measurement; no usable bp_systolic_office measurement Window: 365 days before the check. Another published definition (`esc2024_office_bp@1.0`) gives: not assessable. Citation Adult blood pressure categories: normal, elevated, stage 1, stage 2 (NHLBI, as in the 2017/2025 ACC/AHA guidelines) nhlbi_bp_categories@1.0 In our words: Adult blood pressure (mm Hg): normal below 120/80; elevated 120 to 129 systolic with diastolic below 80; stage 1 130 to 139 or 80 to 89; stage 2 140 or higher or 90 or higher; crisis range above 180 or above 120. Diagnosis needs readings at two or more separate visits. Normal: Less than 120 systolic AND Less than 80 diastolic; Elevated: 120 to 129 AND Less than 80; Stage 1: 130 to 139 OR 80 to 89; Stage 2: 140 or higher OR 90 or higher; Hypertensive Crisis: Higher than 180 OR Higher than 120 National Heart, Lung, and Blood Institute (U.S. National Institutes of Health), High Blood Pressure — Diagnosis (2025) · Blood pressure categories table · source Licence: U.S. government work (public domain). Source checked: opened. No endorsement by the cited bodies is implied. Contested: European guidelines define hypertension at 140/90 (ESC 2024, encoded separately as esc2024_office_bp) while AHA/ACC use 130/80. Not encoded: Measurement technique (seated, rested, correct cuff), averaging of several readings per visit, out-of-office (home, ambulatory) thresholds, white-coat and masked hypertension are not encoded. The 2025 AHA/ACC guideline's own table was not opened; the categories are taken from the NHLBI page. Children and adolescents are not covered (population limited to 18 and older as an interpretation).	Hypertension	None entered	Cannot be assessed no_value
Whole code category, for reference (no code is selected, ranked or suggested): Hypertension Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `I10` Essential (primary) hypertension: distinguishes essential (primary) hypertension (one code); hypertension with heart or kidney disease uses I11-I13 (1 codes in the category). `I10` Essential (primary) hypertension `R03` Abnormal blood-pressure reading, without diagnosis: distinguishes R03.0 elevated blood-pressure reading without diagnosis of hypertension; R03.1 nonspecific low reading (2 codes in the category). `R03.0` Elevated blood-pressure reading, without diagnosis of hypertension `R03.1` Nonspecific low blood-pressure reading 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 Moderate anaemia haemoglobin 104 g/L 2026-11-10 09:05 · LM-P22-01 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	The record supports it; neither stated in the note nor entered Draft a query
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).