Extended criteria (experimental). This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects for CDI staff. The primary surface is Before you sign (kidney, measurement only). All extended pages.

ENC-00003: Camila Lindqvist

74F · MRN51440377 · Cardiology · admitted Thu Oct 29, 2026 08:28 PM · discharged Tue Nov 03, 2026 01:43 PM · attending Dr. Kenji Stavros · 159 cm, 54.3 kg

Documented diagnoses (current)

“malnutrition” · E46 Unspecified protein-calorie malnutrition
“renal insufficiency” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
Principal: “congestive heart failure” · I50.9 Heart failure, unspecified
“hypertension” · I10 Essential (primary) hypertension
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis

Illustrative grouping now: MS-DRG 292 Heart failure and shock with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 292.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria met

Specificity gap

Documented “renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 3) (N17.9).

Trace

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=3.493, t.ratio_s1=1.5, creat_rise_48h=0.56, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	true
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=True, creat_ratio=3.493, t.ratio_s3=3.0, creat_peak=2.55, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=unknown, t.uo_s3_h=24, anuria_hours=unknown, t.anuria_h=12	true
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=3.493, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12	true
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=True, stage2=True, meets_definition=True	3
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.56, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=3, baseline_independent=True	true

Acute blood loss anaemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=F, hgb_nadir=13.66, t.hb_m=13, t.hb_f=12	false
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=0.3, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=False, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.66, anaemic=False	true

Chronic kidney disease

Clinical judgement required

No gap

Not documented; egfr 60 or above; ckd g1-g2 requires markers of kidney damage, which are not assessed here.

Trace

Rule trace (rule ckd v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=304, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=83.5, egfr_late=86.2	86.2
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=83.5, t.g2=60, egfr_late=86.2	false
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=86.2, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G1-G2
outcome: duration_not_shown	`not chronic`	chronic=True	false
outcome: straddles_60	`not both_below_60 and min(egfr_early, egfr_late) < t.g2`	both_below_60=False, egfr_early=83.5, egfr_late=86.2, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=86.2, t.g2=60	true

Heart failure

Clinical judgement required

Clinical judgement required: LVEF 48% (HFmrEF, 41-49%); the type wording and its coding convention need the clinician.

Trace

Rule trace (rule heart_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: np_elevated	`coalesce(bnp_max >= t.bnp, false) or coalesce(ntprobnp_max >= t.ntprobnp, false)`	bnp_max=1071.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	true
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, np_elevated=True, new_o2=False	2
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=48.0, t.ref=40, t.pres=50	midrange
derived: improved	`coalesce(lvef_prior_min <= t.ref and lvef > t.ref and lvef - lvef_prior_min >= t.improved_rise, false)`	lvef_prior_min=unknown, t.ref=40, lvef=48.0, t.improved_rise=10	false
derived: acuity	`case(acute_count >= 2 and hf_history, 'acute on chronic', acute_count >= 2, 'acute', acute_count == 0 and hf_history, 'chronic', null)`	acute_count=2, hf_history=True	acute on chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=midrange	true

Hyponatraemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=136.0, t.profound=125, t.moderate=130, t.low=135	none
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=136.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=136.0, t.low=135	true

Malnutrition

Clinical judgement required

Clinical judgement required: Only one consensus characteristic documented; two are required.

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_pct=60.0, t.a_sev_intake_pct=50, intake_days=11.0, t.a_sev_intake_days=5	false
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=60.0, t.a_mod_intake_pct=75, intake_days=11.0, t.a_mod_intake_days=7	true
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=60.0, t.c_intake_pct=75, intake_days=11.0, t.c_intake_days=30	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=60.0, t.c_intake_pct=75, intake_days=11.0, t.c_intake_days=30	false
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=60.0, wt_loss_pct=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown	4
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	nutr_context=acute, a_sev_intake=False, a_sev_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=unknown	0
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	nutr_context=acute, a_sev_intake=False, a_mod_intake=True, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=unknown, c_mod_wt=unknown	1
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=1	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=1	true

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=74, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=21.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=21.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=21.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=21.5, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=unknown	unknown
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=unknown	true

Acute respiratory failure

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule respiratory_failure v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: measured	`present(spo2_min_ra) or present(pao2_min_ra) or present(pf_min)`	spo2_min_ra=94.0, pao2_min_ra=unknown, pf_min=unknown	true
derived: hypoxemia	`coalesce(spo2_min_ra < t.spo2_ra, false) or coalesce(pao2_min_ra < t.pao2, false) or coalesce(pf_min < t.pf, false)`	spo2_min_ra=94.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	false
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=18.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False	false
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=False	false
outcome: met	`hypoxemia and distress`	hypoxemia=False, distress=False	false
outcome: hypoxemia_only	`hypoxemia`	hypoxemia=False	false
outcome: not_met	`measured and not hypoxemia and o2_max_lpm <= t.o2_low and not adv_resp_support`	measured=True, hypoxemia=False, o2_max_lpm=0.0, t.o2_low=2, adv_resp_support=False	true

Sepsis

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule sepsis v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sirs_temp	`coalesce(temp_max_48h > t.t_hi, false) or coalesce(temp_min_48h < t.t_lo, false)`	temp_max_48h=37.5, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=89.0, t.hr=90	false
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=18.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	false
derived: sirs_wbc	`coalesce(wbc_max_48h > t.wbc_hi, false) or coalesce(wbc_min_48h < t.wbc_lo, false) or coalesce(bands_max_48h > t.bands, false)`	wbc_max_48h=9.46, t.wbc_hi=12, wbc_min_48h=8.46, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	false
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=False, sirs_hr=False, sirs_rr=False, sirs_wbc=False	0
derived: sofa_resp	`coalesce(case(pf_min_48h < 100 and adv_resp_support, 4, pf_min_48h < 200 and adv_resp_support, 3, pf_min_48h < 300, 2, pf_min_48h < 400, 1, 0), 0)`	pf_min_48h=unknown, adv_resp_support=False	0
derived: sofa_coag	`coalesce(case(platelets_min_48h < 20, 4, platelets_min_48h < 50, 3, platelets_min_48h < 100, 2, platelets_min_48h < 150, 1, 0), 0)`	platelets_min_48h=208.0	0
derived: sofa_liver	`coalesce(case(bili_max_48h >= 12, 4, bili_max_48h >= 6, 3, bili_max_48h >= 2, 2, bili_max_48h >= 1.2, 1, 0), 0)`	bili_max_48h=1.0	0
derived: sofa_cardio	`coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0)`	norepi_max_48h=0.0, map_min_48h=76.0	0
derived: sofa_cns	`coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0)`	gcs_min_48h=15.0	0
derived: sofa_renal	`coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0)`	creat_max_48h=2.55	2
derived: sofa_renal_baseline	`coalesce(case(creat_baseline >= 5, 4, creat_baseline >= 3.5, 3, creat_baseline >= 2, 2, creat_baseline >= 1.2, 1, 0), 0)`	creat_baseline=0.73	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=0, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=2, sofa_renal_baseline=0	2
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=False, sofa_delta=2, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, sirs_count=0, t.sirs_min=2	false
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=False, norepi_max_48h=0.0, lactate_max_48h=unknown, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=False	true

Structured data

Labs (34)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000074	Sat Nov 01, 2025 09:15 AM	creatinine	0.75 mg/dL
LAB-000075	Tue Sep 01, 2026 10:05 AM	creatinine	0.73 mg/dL
LAB-000076	Thu Oct 29, 2026 09:28 PM	creatinine	1.99 mg/dL
LAB-000082	Thu Oct 29, 2026 09:28 PM	bnp	1071.0 pg/mL
LAB-000083	Thu Oct 29, 2026 09:28 PM	sodium	141.0 mmol/L
LAB-000089	Thu Oct 29, 2026 09:28 PM	hemoglobin	13.95 g/dL
LAB-000095	Thu Oct 29, 2026 09:28 PM	wbc	8.74 x10^3/uL
LAB-000096	Thu Oct 29, 2026 09:28 PM	platelets	208.0 x10^3/uL
LAB-000107	Thu Oct 29, 2026 09:28 PM	bilirubin	1.0 mg/dL
LAB-000077	Fri Oct 30, 2026 05:00 AM	creatinine	2.55 mg/dL
LAB-000084	Fri Oct 30, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000090	Fri Oct 30, 2026 05:00 AM	hemoglobin	13.8 g/dL
LAB-000097	Fri Oct 30, 2026 05:00 AM	wbc	8.46 x10^3/uL
LAB-000098	Fri Oct 30, 2026 05:00 AM	platelets	295.0 x10^3/uL
LAB-000078	Sat Oct 31, 2026 05:00 AM	creatinine	2.29 mg/dL
LAB-000085	Sat Oct 31, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000091	Sat Oct 31, 2026 05:00 AM	hemoglobin	13.94 g/dL
LAB-000099	Sat Oct 31, 2026 05:00 AM	wbc	9.46 x10^3/uL
LAB-000100	Sat Oct 31, 2026 05:00 AM	platelets	294.0 x10^3/uL
LAB-000079	Sun Nov 01, 2026 05:00 AM	creatinine	1.91 mg/dL
LAB-000086	Sun Nov 01, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000092	Sun Nov 01, 2026 05:00 AM	hemoglobin	13.66 g/dL
LAB-000101	Sun Nov 01, 2026 05:00 AM	wbc	9.3 x10^3/uL
LAB-000102	Sun Nov 01, 2026 05:00 AM	platelets	266.0 x10^3/uL
LAB-000080	Mon Nov 02, 2026 05:00 AM	creatinine	1.58 mg/dL
LAB-000087	Mon Nov 02, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-000093	Mon Nov 02, 2026 05:00 AM	hemoglobin	13.71 g/dL
LAB-000103	Mon Nov 02, 2026 05:00 AM	wbc	8.28 x10^3/uL
LAB-000104	Mon Nov 02, 2026 05:00 AM	platelets	293.0 x10^3/uL
LAB-000081	Tue Nov 03, 2026 05:00 AM	creatinine	1.4 mg/dL
LAB-000088	Tue Nov 03, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-000094	Tue Nov 03, 2026 05:00 AM	hemoglobin	13.67 g/dL
LAB-000105	Tue Nov 03, 2026 05:00 AM	wbc	8.83 x10^3/uL
LAB-000106	Tue Nov 03, 2026 05:00 AM	platelets	212.0 x10^3/uL

Vitals (90)

Vitals
Row	When	Kind	Value	Detail
VIT-000215	Thu Oct 29, 2026 08:48 PM	spo2	98.0	room air
VIT-000216	Thu Oct 29, 2026 08:48 PM	rr	15.0
VIT-000245	Thu Oct 29, 2026 08:48 PM	temp_c	36.6
VIT-000246	Thu Oct 29, 2026 08:48 PM	hr	74.0
VIT-000247	Thu Oct 29, 2026 08:48 PM	map	90.0
VIT-000248	Thu Oct 29, 2026 08:48 PM	gcs	15.0
VIT-000217	Fri Oct 30, 2026 04:48 AM	spo2	98.0	room air
VIT-000218	Fri Oct 30, 2026 04:48 AM	rr	14.0
VIT-000249	Fri Oct 30, 2026 04:48 AM	temp_c	36.9
VIT-000250	Fri Oct 30, 2026 04:48 AM	hr	80.0
VIT-000251	Fri Oct 30, 2026 04:48 AM	map	86.0
VIT-000252	Fri Oct 30, 2026 04:48 AM	gcs	15.0
VIT-000219	Fri Oct 30, 2026 12:48 PM	spo2	95.0	room air
VIT-000220	Fri Oct 30, 2026 12:48 PM	rr	18.0
VIT-000253	Fri Oct 30, 2026 12:48 PM	temp_c	37.3
VIT-000254	Fri Oct 30, 2026 12:48 PM	hr	80.0
VIT-000255	Fri Oct 30, 2026 12:48 PM	map	76.0
VIT-000256	Fri Oct 30, 2026 12:48 PM	gcs	15.0
VIT-000221	Fri Oct 30, 2026 08:48 PM	spo2	96.0	room air
VIT-000222	Fri Oct 30, 2026 08:48 PM	rr	15.0
VIT-000257	Fri Oct 30, 2026 08:48 PM	temp_c	36.9
VIT-000258	Fri Oct 30, 2026 08:48 PM	hr	68.0
VIT-000259	Fri Oct 30, 2026 08:48 PM	map	91.0
VIT-000260	Fri Oct 30, 2026 08:48 PM	gcs	15.0
VIT-000223	Sat Oct 31, 2026 04:48 AM	spo2	99.0	room air
VIT-000224	Sat Oct 31, 2026 04:48 AM	rr	17.0
VIT-000261	Sat Oct 31, 2026 04:48 AM	temp_c	36.7
VIT-000262	Sat Oct 31, 2026 04:48 AM	hr	79.0
VIT-000263	Sat Oct 31, 2026 04:48 AM	map	89.0
VIT-000264	Sat Oct 31, 2026 04:48 AM	gcs	15.0
VIT-000225	Sat Oct 31, 2026 12:48 PM	spo2	99.0	room air
VIT-000226	Sat Oct 31, 2026 12:48 PM	rr	14.0
VIT-000265	Sat Oct 31, 2026 12:48 PM	temp_c	37.5
VIT-000266	Sat Oct 31, 2026 12:48 PM	hr	89.0
VIT-000267	Sat Oct 31, 2026 12:48 PM	map	78.0
VIT-000268	Sat Oct 31, 2026 12:48 PM	gcs	15.0
VIT-000227	Sat Oct 31, 2026 08:48 PM	spo2	96.0	room air
VIT-000228	Sat Oct 31, 2026 08:48 PM	rr	15.0
VIT-000269	Sat Oct 31, 2026 08:48 PM	temp_c	37.4
VIT-000270	Sat Oct 31, 2026 08:48 PM	hr	92.0
VIT-000271	Sat Oct 31, 2026 08:48 PM	map	91.0
VIT-000272	Sat Oct 31, 2026 08:48 PM	gcs	15.0
VIT-000229	Sun Nov 01, 2026 04:48 AM	spo2	98.0	room air
VIT-000230	Sun Nov 01, 2026 04:48 AM	rr	14.0
VIT-000273	Sun Nov 01, 2026 04:48 AM	temp_c	37.5
VIT-000274	Sun Nov 01, 2026 04:48 AM	hr	71.0
VIT-000275	Sun Nov 01, 2026 04:48 AM	map	80.0
VIT-000276	Sun Nov 01, 2026 04:48 AM	gcs	15.0
VIT-000231	Sun Nov 01, 2026 12:48 PM	spo2	97.0	room air
VIT-000232	Sun Nov 01, 2026 12:48 PM	rr	15.0
VIT-000277	Sun Nov 01, 2026 12:48 PM	temp_c	37.3
VIT-000278	Sun Nov 01, 2026 12:48 PM	hr	68.0
VIT-000279	Sun Nov 01, 2026 12:48 PM	map	77.0
VIT-000280	Sun Nov 01, 2026 12:48 PM	gcs	15.0
VIT-000233	Sun Nov 01, 2026 08:48 PM	spo2	97.0	room air
VIT-000234	Sun Nov 01, 2026 08:48 PM	rr	14.0
VIT-000281	Sun Nov 01, 2026 08:48 PM	temp_c	36.8
VIT-000282	Sun Nov 01, 2026 08:48 PM	hr	78.0
VIT-000283	Sun Nov 01, 2026 08:48 PM	map	85.0
VIT-000284	Sun Nov 01, 2026 08:48 PM	gcs	15.0
VIT-000235	Mon Nov 02, 2026 04:48 AM	spo2	98.0	room air
VIT-000236	Mon Nov 02, 2026 04:48 AM	rr	15.0
VIT-000285	Mon Nov 02, 2026 04:48 AM	temp_c	36.6
VIT-000286	Mon Nov 02, 2026 04:48 AM	hr	88.0
VIT-000287	Mon Nov 02, 2026 04:48 AM	map	80.0
VIT-000288	Mon Nov 02, 2026 04:48 AM	gcs	15.0
VIT-000237	Mon Nov 02, 2026 12:48 PM	spo2	98.0	room air
VIT-000238	Mon Nov 02, 2026 12:48 PM	rr	18.0
VIT-000289	Mon Nov 02, 2026 12:48 PM	temp_c	37.6
VIT-000290	Mon Nov 02, 2026 12:48 PM	hr	69.0
VIT-000291	Mon Nov 02, 2026 12:48 PM	map	92.0
VIT-000292	Mon Nov 02, 2026 12:48 PM	gcs	15.0
VIT-000239	Mon Nov 02, 2026 08:48 PM	spo2	99.0	room air
VIT-000240	Mon Nov 02, 2026 08:48 PM	rr	18.0
VIT-000293	Mon Nov 02, 2026 08:48 PM	temp_c	37.5
VIT-000294	Mon Nov 02, 2026 08:48 PM	hr	89.0
VIT-000295	Mon Nov 02, 2026 08:48 PM	map	80.0
VIT-000296	Mon Nov 02, 2026 08:48 PM	gcs	15.0
VIT-000241	Tue Nov 03, 2026 04:48 AM	spo2	94.0	room air
VIT-000242	Tue Nov 03, 2026 04:48 AM	rr	14.0
VIT-000297	Tue Nov 03, 2026 04:48 AM	temp_c	37.0
VIT-000298	Tue Nov 03, 2026 04:48 AM	hr	70.0
VIT-000299	Tue Nov 03, 2026 04:48 AM	map	92.0
VIT-000300	Tue Nov 03, 2026 04:48 AM	gcs	15.0
VIT-000243	Tue Nov 03, 2026 12:48 PM	spo2	97.0	room air
VIT-000244	Tue Nov 03, 2026 12:48 PM	rr	16.0
VIT-000301	Tue Nov 03, 2026 12:48 PM	temp_c	37.3
VIT-000302	Tue Nov 03, 2026 12:48 PM	hr	73.0
VIT-000303	Tue Nov 03, 2026 12:48 PM	map	79.0
VIT-000304	Tue Nov 03, 2026 12:48 PM	gcs	15.0

Medications, orders, echo, history (8)

MED-000016 10-29 08:00 furosemide 40 mg IV
MED-000017 10-29 20:00 furosemide 40 mg IV
MED-000018 10-30 08:00 furosemide 40 mg IV
MED-000019 10-30 20:00 furosemide 40 mg IV
MED-000020 10-31 08:00 furosemide 40 mg IV
MED-000021 10-31 20:00 furosemide 40 mg IV
ECH-000003 2026-10-31 echo LVEF 48.0%
HX-000003 history: heart failure with reduced ejection fraction

Notes

History and physical · DOC-000009 · Dr. Kenji Stavros (attending) · Thu Oct 29, 2026 11:28 PM

Source document DOC-000009: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Camila Lindqvist   MRN: MRN51440377   Admitted: 2026-10-29 20:28
Service: Cardiology   Attending: Dr. Kenji Stavros

History of present illness: 74-year-old woman admitted with congestive heart failure. 
Past medical history: heart failure with reduced ejection fraction, hypertension, GERD.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Congestive heart failure: diuresis and daily weights; monitor electrolytes.

Nutrition assessment · DOC-000008 · Vera Pemberton, RD (dietitian) · Fri Oct 30, 2026 11:28 PM

Cited facts from this note (6)

fat_loss: none · cited p. 1, line 7 · confidence 0.90

Show source for fat_loss

… acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… 0% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.
intake_days: 11 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
intake_pct: 60 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
muscle_loss: none · cited p. 1, line 7 · confidence 0.90

Show source for muscle_loss

… ted energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. Assessment: at risk; continue calorie counts.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Camila Lindqvist MRN: MRN51440377 Context: acute illness Intake: estimated energy intake 60% of needs for 11 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of sub …

Source document DOC-000008: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Camila Lindqvist   MRN: MRN51440377

Context: acute illness
Intake: estimated energy intake 60% of needs for 11 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: at risk; continue calorie counts.

Progress note · DOC-000010 · Dr. Kenji Stavros (attending) · Sat Oct 31, 2026 09:28 PM

Source document DOC-000010: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Camila Lindqvist   MRN: MRN51440377   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Congestive heart failure: continue current management.
2. Malnutrition: dietitian following.
3. Renal insufficiency: trend creatinine, avoid nephrotoxins.

Attending: Dr. Kenji Stavros

Discharge summary · DOC-000011 · Dr. Kenji Stavros (attending) · Tue Nov 03, 2026 01:43 PM

Source document DOC-000011: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Camila Lindqvist   MRN: MRN51440377
Admitted 2026-10-29; discharged 2026-11-03.

Discharge diagnoses:
- malnutrition
- renal insufficiency
- congestive heart failure
- hypertension
- GERD

Disposition: home with follow-up.