P28 KE-P28 · 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.

Side-panel conditions check FRUN-00028 · front-engine 1.2 · replay a69b899f5ec2e23c…

Library check LRUN-00028 · library_default_set@1.1 · library-engine 1.1 · replay 28ba37faa0b6987e… · 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).	CKD stage 3a	None entered	Entered or stated without support in the record The note says “CKD stage 3a”; results 240 days apart are 60 or above (filtering rate 72.3 on 2026-03-16 and 67.7 on 2026-11-11), so the threshold of below 60 is not met. Draft a query
Code-family reference: 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
Hyponatraemia measured	`ese2014_hyponatraemia@1.0` Draft · pending review Criteria not met: 135 mmol/L or above sodium serum 139 mmol/L 2026-11-11 09:05 · LM-P28-02 Window: 14 days before the check. Citation Hyponatraemia, presence only (ESE/ESICM/ERA-EDTA 2014) 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), Clinical practice guideline on diagnosis and treatment of hyponatraemia (2014) · Abstract · source Licence: cited source; wording is ours (numbers restated, no text reproduced). Source checked: opened. No endorsement by the cited bodies is implied. Not encoded: The guideline's severity bands (mild, moderate, profound) and its acute (<48 h) versus chronic classification: the full text could not be opened (publisher pages refused or errored), so they are not encoded. See the catalogue entry ese2014_hyponatraemia_severity. Correction for hyperglycaemia, measurement artefacts (pseudohyponatraemia) and symptoms are not assessed.	Not stated	`E87.1` Hypo-osmolality and hyponatremia (visit diagnosis list (synthetic))	Entered or stated without support in the record Draft a query
Code-family reference: Hyponatraemia Coders only reference for coders — the clinician's documented statement governs; the software does not assign codes `E87` Other disorders of fluid, electrolyte and acid-base balance: distinguishes E87.1 hypo-osmolality and hyponatremia (one code; no severity axis) (14 codes in the category). `E87.0` Hyperosmolality and hypernatremia `E87.1` Hypo-osmolality and hyponatremia `E87.20` Acidosis, unspecified `E87.21` Acute metabolic acidosis `E87.22` Chronic metabolic acidosis `E87.29` Other acidosis `E87.3` Alkalosis `E87.4` Mixed disorder of acid-base balance `E87.5` Hyperkalemia `E87.6` Hypokalemia `E87.70` Fluid overload, unspecified `E87.71` Transfusion associated circulatory overload `E87.79` Other fluid overload `E87.8` Other disorders of electrolyte and fluid balance, not elsewhere classified Source: official ICD-10-CM FY2027 code descriptions (extract in library/data/code_reference_fy2027.json).