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-00008: Rosalind Yardley

54M · MRN60745118 · Hospital Medicine · admitted Mon Oct 26, 2026 11:03 AM · discharged Tue Nov 03, 2026 02:09 PM · attending Dr. Cyrus Ellingham · resident Dr. Noor Halvorsen · 162 cm, 118.0 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“hypoxia” · R09.02 Hypoxemia
“sacral decubitus ulcer” · L89.159 Pressure ulcer of sacral region, unspecified stage
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 871 Septicemia or severe sepsis without MV >96 hours with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 871.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria not met

No gap

Not documented and not supported.

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=1.06, t.ratio_s1=1.5, creat_rise_48h=0.05, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, t.uo_s1_h=6	false
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=False, creat_ratio=1.06, t.ratio_s3=3.0, creat_peak=1.06, 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	false
derived: stage2	`creat_ratio >= t.ratio_s2 or coalesce(uo_hours_lt_0_5 >= t.uo_s2_h, false)`	creat_ratio=1.06, t.ratio_s2=2.0, uo_hours_lt_0_5=unknown, t.uo_s2_h=12	false
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=False, meets_definition=False	0
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.05, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=0, baseline_independent=True	false
outcome: aki_presumed_baseline	`stage >= 1`	stage=0	false
outcome: not_met	`stage == 0`	stage=0	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=M, hgb_nadir=14.06, 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=0.5, t.drop_major=2.0, prbc_units=0, t.prbc_major=2	false
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=True, anaemic=False, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=False, hgb_drop=0.5, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.06, 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=365, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=90.5, egfr_late=89.4	90.5
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=90.5, t.g2=60, egfr_late=89.4	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=90.5, 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=90.5, egfr_late=89.4, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=90.5, t.g2=60	true

Heart failure

Clinical judgement required

No gap

Not documented; only one acute indicator; acuity needs clinical judgement.

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=unknown, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=False, np_elevated=False, new_o2=True	1
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=unknown, t.ref=40, t.pres=50	unknown
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=unknown, 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=1, hf_history=False	unknown
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=unknown	unknown
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=unknown, acuity=unknown	unknown
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	hf_type=unknown, acuity=unknown	unknown
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	hf_type=unknown, acuity=unknown	unknown
outcome: one_indicator	`acute_count == 1`	acute_count=1	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

Criteria not met

No gap

Not documented and not supported.

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=100.0, t.a_sev_intake_pct=50, intake_days=unknown, 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=100.0, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	false
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=100.0, t.c_intake_pct=75, intake_days=unknown, 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=100.0, t.c_intake_pct=75, intake_days=unknown, 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=100.0, 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=False, 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	0
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=0	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=0	false
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=0, n_assessed=4	true

Obesity

Criteria met

Specificity gap

Criteria support Obesity, class 3 (E66.813); no corresponding diagnosis is documented.

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=54, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=45.0, t.c3=40	true

Pressure injury

Criteria met

Specificity gap

Documented “sacral decubitus ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 2 (L89.152).

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=sacral	true
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=2	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=2	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=2	true

Acute respiratory failure

Clinical judgement required

Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

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=86.0, 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=86.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=23.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False	false
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=True	false
outcome: met	`hypoxemia and distress`	hypoxemia=True, distress=False	false
outcome: hypoxemia_only	`hypoxemia`	hypoxemia=True	true

Sepsis

Criteria met

No gap

Supported as documented (A41.9).

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=38.9, t.t_hi=38, temp_min_48h=38.5, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=121.0, t.hr=90	true
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=23.0, t.rr=20, paco2_min_48h=unknown, t.paco2=32	true
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=16.71, t.wbc_hi=12, wbc_min_48h=15.7, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	true
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=True, sirs_hr=True, sirs_rr=True, sirs_wbc=True	4
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=84.0	2
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=0.53	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=64.0	1
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=1.06	0
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=1.0	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=0, sofa_coag=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	3
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=3, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=4, t.sirs_min=2	true
derived: shock	`sepsis3 and norepi_max_48h > 0 and coalesce(lactate_max_48h > t.lactate, false)`	sepsis3=True, norepi_max_48h=0.0, lactate_max_48h=2.33, t.lactate=2	false
outcome: no_infection	`not infection_documented`	infection_documented=True	false
outcome: septic_shock	`shock`	shock=False	false
outcome: both	`sepsis3 and sepsis2`	sepsis3=True, sepsis2=True	true

Structured data

Labs (49)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000249	Sun Sep 14, 2025 09:15 AM	creatinine	0.99 mg/dL
LAB-000250	Mon Sep 14, 2026 10:05 AM	creatinine	1.0 mg/dL
LAB-000251	Mon Oct 26, 2026 12:03 PM	creatinine	1.04 mg/dL
LAB-000260	Mon Oct 26, 2026 12:03 PM	sodium	142.0 mmol/L
LAB-000269	Mon Oct 26, 2026 12:03 PM	hemoglobin	14.2 g/dL
LAB-000278	Mon Oct 26, 2026 12:03 PM	wbc	15.7 x10^3/uL
LAB-000279	Mon Oct 26, 2026 12:03 PM	platelets	84.0 x10^3/uL
LAB-000296	Mon Oct 26, 2026 12:03 PM	bilirubin	0.53 mg/dL
LAB-000297	Mon Oct 26, 2026 12:03 PM	lactate	2.33 mmol/L
LAB-000252	Tue Oct 27, 2026 05:00 AM	creatinine	1.05 mg/dL
LAB-000261	Tue Oct 27, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-000270	Tue Oct 27, 2026 05:00 AM	hemoglobin	14.14 g/dL
LAB-000280	Tue Oct 27, 2026 05:00 AM	wbc	16.08 x10^3/uL
LAB-000281	Tue Oct 27, 2026 05:00 AM	platelets	84.0 x10^3/uL
LAB-000253	Wed Oct 28, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-000262	Wed Oct 28, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-000271	Wed Oct 28, 2026 05:00 AM	hemoglobin	14.19 g/dL
LAB-000282	Wed Oct 28, 2026 05:00 AM	wbc	16.71 x10^3/uL
LAB-000283	Wed Oct 28, 2026 05:00 AM	platelets	86.0 x10^3/uL
LAB-000254	Thu Oct 29, 2026 05:00 AM	creatinine	1.01 mg/dL
LAB-000263	Thu Oct 29, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000272	Thu Oct 29, 2026 05:00 AM	hemoglobin	14.18 g/dL
LAB-000284	Thu Oct 29, 2026 05:00 AM	wbc	10.12 x10^3/uL
LAB-000285	Thu Oct 29, 2026 05:00 AM	platelets	252.0 x10^3/uL
LAB-000255	Fri Oct 30, 2026 05:00 AM	creatinine	0.99 mg/dL
LAB-000264	Fri Oct 30, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000273	Fri Oct 30, 2026 05:00 AM	hemoglobin	14.37 g/dL
LAB-000286	Fri Oct 30, 2026 05:00 AM	wbc	7.08 x10^3/uL
LAB-000287	Fri Oct 30, 2026 05:00 AM	platelets	283.0 x10^3/uL
LAB-000256	Sat Oct 31, 2026 05:00 AM	creatinine	1.04 mg/dL
LAB-000265	Sat Oct 31, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000274	Sat Oct 31, 2026 05:00 AM	hemoglobin	14.32 g/dL
LAB-000288	Sat Oct 31, 2026 05:00 AM	wbc	9.74 x10^3/uL
LAB-000289	Sat Oct 31, 2026 05:00 AM	platelets	297.0 x10^3/uL
LAB-000257	Sun Nov 01, 2026 05:00 AM	creatinine	1.03 mg/dL
LAB-000266	Sun Nov 01, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-000275	Sun Nov 01, 2026 05:00 AM	hemoglobin	14.55 g/dL
LAB-000290	Sun Nov 01, 2026 05:00 AM	wbc	10.35 x10^3/uL
LAB-000291	Sun Nov 01, 2026 05:00 AM	platelets	296.0 x10^3/uL
LAB-000258	Mon Nov 02, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-000267	Mon Nov 02, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-000276	Mon Nov 02, 2026 05:00 AM	hemoglobin	14.06 g/dL
LAB-000292	Mon Nov 02, 2026 05:00 AM	wbc	7.6 x10^3/uL
LAB-000293	Mon Nov 02, 2026 05:00 AM	platelets	297.0 x10^3/uL
LAB-000259	Tue Nov 03, 2026 05:00 AM	creatinine	1.01 mg/dL
LAB-000268	Tue Nov 03, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000277	Tue Nov 03, 2026 05:00 AM	hemoglobin	14.46 g/dL
LAB-000294	Tue Nov 03, 2026 05:00 AM	wbc	9.59 x10^3/uL
LAB-000295	Tue Nov 03, 2026 05:00 AM	platelets	175.0 x10^3/uL

Vitals (174)

Vitals
Row	When	Kind	Value	Detail
VIT-000706	Mon Oct 26, 2026 11:23 AM	spo2	86.0	room air
VIT-000707	Mon Oct 26, 2026 11:23 AM	rr	22.0
VIT-000780	Mon Oct 26, 2026 11:23 AM	temp_c	38.5
VIT-000781	Mon Oct 26, 2026 11:23 AM	hr	106.0
VIT-000782	Mon Oct 26, 2026 11:23 AM	map	68.0
VIT-000783	Mon Oct 26, 2026 11:23 AM	gcs	15.0
VIT-000708	Mon Oct 26, 2026 07:23 PM	spo2	93.0	nasal cannula
VIT-000709	Mon Oct 26, 2026 07:23 PM	rr	22.0
VIT-000710	Mon Oct 26, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000784	Mon Oct 26, 2026 07:23 PM	temp_c	38.6
VIT-000785	Mon Oct 26, 2026 07:23 PM	hr	105.0
VIT-000786	Mon Oct 26, 2026 07:23 PM	map	67.0
VIT-000787	Mon Oct 26, 2026 07:23 PM	gcs	15.0
VIT-000711	Tue Oct 27, 2026 03:23 AM	spo2	94.0	nasal cannula
VIT-000712	Tue Oct 27, 2026 03:23 AM	rr	18.0
VIT-000713	Tue Oct 27, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000788	Tue Oct 27, 2026 03:23 AM	temp_c	38.9
VIT-000789	Tue Oct 27, 2026 03:23 AM	hr	121.0
VIT-000790	Tue Oct 27, 2026 03:23 AM	map	67.0
VIT-000791	Tue Oct 27, 2026 03:23 AM	gcs	15.0
VIT-000714	Tue Oct 27, 2026 11:23 AM	spo2	92.0	nasal cannula
VIT-000715	Tue Oct 27, 2026 11:23 AM	rr	19.0
VIT-000716	Tue Oct 27, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000792	Tue Oct 27, 2026 11:23 AM	temp_c	38.5
VIT-000793	Tue Oct 27, 2026 11:23 AM	hr	103.0
VIT-000794	Tue Oct 27, 2026 11:23 AM	map	64.0
VIT-000795	Tue Oct 27, 2026 11:23 AM	gcs	15.0
VIT-000717	Tue Oct 27, 2026 07:23 PM	spo2	96.0	nasal cannula
VIT-000718	Tue Oct 27, 2026 07:23 PM	rr	23.0
VIT-000719	Tue Oct 27, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000796	Tue Oct 27, 2026 07:23 PM	temp_c	38.9
VIT-000797	Tue Oct 27, 2026 07:23 PM	hr	119.0
VIT-000798	Tue Oct 27, 2026 07:23 PM	map	64.0
VIT-000799	Tue Oct 27, 2026 07:23 PM	gcs	15.0
VIT-000720	Wed Oct 28, 2026 03:23 AM	spo2	96.0	nasal cannula
VIT-000721	Wed Oct 28, 2026 03:23 AM	rr	18.0
VIT-000722	Wed Oct 28, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000800	Wed Oct 28, 2026 03:23 AM	temp_c	38.5
VIT-000801	Wed Oct 28, 2026 03:23 AM	hr	118.0
VIT-000802	Wed Oct 28, 2026 03:23 AM	map	64.0
VIT-000803	Wed Oct 28, 2026 03:23 AM	gcs	15.0
VIT-000723	Wed Oct 28, 2026 11:23 AM	spo2	94.0	nasal cannula
VIT-000724	Wed Oct 28, 2026 11:23 AM	rr	19.0
VIT-000725	Wed Oct 28, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000804	Wed Oct 28, 2026 11:23 AM	temp_c	36.9
VIT-000805	Wed Oct 28, 2026 11:23 AM	hr	83.0
VIT-000806	Wed Oct 28, 2026 11:23 AM	map	86.0
VIT-000807	Wed Oct 28, 2026 11:23 AM	gcs	15.0
VIT-000726	Wed Oct 28, 2026 07:23 PM	spo2	94.0	nasal cannula
VIT-000727	Wed Oct 28, 2026 07:23 PM	rr	22.0
VIT-000728	Wed Oct 28, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000808	Wed Oct 28, 2026 07:23 PM	temp_c	36.9
VIT-000809	Wed Oct 28, 2026 07:23 PM	hr	85.0
VIT-000810	Wed Oct 28, 2026 07:23 PM	map	86.0
VIT-000811	Wed Oct 28, 2026 07:23 PM	gcs	15.0
VIT-000729	Thu Oct 29, 2026 03:23 AM	spo2	92.0	nasal cannula
VIT-000730	Thu Oct 29, 2026 03:23 AM	rr	23.0
VIT-000731	Thu Oct 29, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000812	Thu Oct 29, 2026 03:23 AM	temp_c	37.0
VIT-000813	Thu Oct 29, 2026 03:23 AM	hr	89.0
VIT-000814	Thu Oct 29, 2026 03:23 AM	map	75.0
VIT-000815	Thu Oct 29, 2026 03:23 AM	gcs	15.0
VIT-000732	Thu Oct 29, 2026 11:23 AM	spo2	95.0	nasal cannula
VIT-000733	Thu Oct 29, 2026 11:23 AM	rr	21.0
VIT-000734	Thu Oct 29, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000816	Thu Oct 29, 2026 11:23 AM	temp_c	37.1
VIT-000817	Thu Oct 29, 2026 11:23 AM	hr	85.0
VIT-000818	Thu Oct 29, 2026 11:23 AM	map	84.0
VIT-000819	Thu Oct 29, 2026 11:23 AM	gcs	15.0
VIT-000735	Thu Oct 29, 2026 07:23 PM	spo2	96.0	nasal cannula
VIT-000736	Thu Oct 29, 2026 07:23 PM	rr	20.0
VIT-000737	Thu Oct 29, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000820	Thu Oct 29, 2026 07:23 PM	temp_c	36.9
VIT-000821	Thu Oct 29, 2026 07:23 PM	hr	84.0
VIT-000822	Thu Oct 29, 2026 07:23 PM	map	88.0
VIT-000823	Thu Oct 29, 2026 07:23 PM	gcs	15.0
VIT-000738	Fri Oct 30, 2026 03:23 AM	spo2	93.0	nasal cannula
VIT-000739	Fri Oct 30, 2026 03:23 AM	rr	19.0
VIT-000740	Fri Oct 30, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000824	Fri Oct 30, 2026 03:23 AM	temp_c	36.7
VIT-000825	Fri Oct 30, 2026 03:23 AM	hr	77.0
VIT-000826	Fri Oct 30, 2026 03:23 AM	map	76.0
VIT-000827	Fri Oct 30, 2026 03:23 AM	gcs	15.0
VIT-000741	Fri Oct 30, 2026 11:23 AM	spo2	96.0	nasal cannula
VIT-000742	Fri Oct 30, 2026 11:23 AM	rr	22.0
VIT-000743	Fri Oct 30, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000828	Fri Oct 30, 2026 11:23 AM	temp_c	37.3
VIT-000829	Fri Oct 30, 2026 11:23 AM	hr	88.0
VIT-000830	Fri Oct 30, 2026 11:23 AM	map	74.0
VIT-000831	Fri Oct 30, 2026 11:23 AM	gcs	15.0
VIT-000744	Fri Oct 30, 2026 07:23 PM	spo2	96.0	nasal cannula
VIT-000745	Fri Oct 30, 2026 07:23 PM	rr	23.0
VIT-000746	Fri Oct 30, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000832	Fri Oct 30, 2026 07:23 PM	temp_c	36.8
VIT-000833	Fri Oct 30, 2026 07:23 PM	hr	79.0
VIT-000834	Fri Oct 30, 2026 07:23 PM	map	86.0
VIT-000835	Fri Oct 30, 2026 07:23 PM	gcs	15.0
VIT-000747	Sat Oct 31, 2026 03:23 AM	spo2	95.0	nasal cannula
VIT-000748	Sat Oct 31, 2026 03:23 AM	rr	22.0
VIT-000749	Sat Oct 31, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000836	Sat Oct 31, 2026 03:23 AM	temp_c	36.7
VIT-000837	Sat Oct 31, 2026 03:23 AM	hr	89.0
VIT-000838	Sat Oct 31, 2026 03:23 AM	map	88.0
VIT-000839	Sat Oct 31, 2026 03:23 AM	gcs	15.0
VIT-000750	Sat Oct 31, 2026 11:23 AM	spo2	94.0	nasal cannula
VIT-000751	Sat Oct 31, 2026 11:23 AM	rr	18.0
VIT-000752	Sat Oct 31, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000840	Sat Oct 31, 2026 11:23 AM	temp_c	37.6
VIT-000841	Sat Oct 31, 2026 11:23 AM	hr	86.0
VIT-000842	Sat Oct 31, 2026 11:23 AM	map	87.0
VIT-000843	Sat Oct 31, 2026 11:23 AM	gcs	15.0
VIT-000753	Sat Oct 31, 2026 07:23 PM	spo2	94.0	nasal cannula
VIT-000754	Sat Oct 31, 2026 07:23 PM	rr	23.0
VIT-000755	Sat Oct 31, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000844	Sat Oct 31, 2026 07:23 PM	temp_c	36.9
VIT-000845	Sat Oct 31, 2026 07:23 PM	hr	85.0
VIT-000846	Sat Oct 31, 2026 07:23 PM	map	88.0
VIT-000847	Sat Oct 31, 2026 07:23 PM	gcs	15.0
VIT-000756	Sun Nov 01, 2026 03:23 AM	spo2	94.0	nasal cannula
VIT-000757	Sun Nov 01, 2026 03:23 AM	rr	19.0
VIT-000758	Sun Nov 01, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000848	Sun Nov 01, 2026 03:23 AM	temp_c	36.7
VIT-000849	Sun Nov 01, 2026 03:23 AM	hr	85.0
VIT-000850	Sun Nov 01, 2026 03:23 AM	map	81.0
VIT-000851	Sun Nov 01, 2026 03:23 AM	gcs	15.0
VIT-000759	Sun Nov 01, 2026 11:23 AM	spo2	94.0	nasal cannula
VIT-000760	Sun Nov 01, 2026 11:23 AM	rr	23.0
VIT-000761	Sun Nov 01, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000852	Sun Nov 01, 2026 11:23 AM	temp_c	36.7
VIT-000853	Sun Nov 01, 2026 11:23 AM	hr	86.0
VIT-000854	Sun Nov 01, 2026 11:23 AM	map	80.0
VIT-000855	Sun Nov 01, 2026 11:23 AM	gcs	15.0
VIT-000762	Sun Nov 01, 2026 07:23 PM	spo2	96.0	nasal cannula
VIT-000763	Sun Nov 01, 2026 07:23 PM	rr	21.0
VIT-000764	Sun Nov 01, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000856	Sun Nov 01, 2026 07:23 PM	temp_c	37.6
VIT-000857	Sun Nov 01, 2026 07:23 PM	hr	88.0
VIT-000858	Sun Nov 01, 2026 07:23 PM	map	91.0
VIT-000859	Sun Nov 01, 2026 07:23 PM	gcs	15.0
VIT-000765	Mon Nov 02, 2026 03:23 AM	spo2	93.0	nasal cannula
VIT-000766	Mon Nov 02, 2026 03:23 AM	rr	21.0
VIT-000767	Mon Nov 02, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000860	Mon Nov 02, 2026 03:23 AM	temp_c	37.5
VIT-000861	Mon Nov 02, 2026 03:23 AM	hr	86.0
VIT-000862	Mon Nov 02, 2026 03:23 AM	map	87.0
VIT-000863	Mon Nov 02, 2026 03:23 AM	gcs	15.0
VIT-000768	Mon Nov 02, 2026 11:23 AM	spo2	93.0	nasal cannula
VIT-000769	Mon Nov 02, 2026 11:23 AM	rr	18.0
VIT-000770	Mon Nov 02, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000864	Mon Nov 02, 2026 11:23 AM	temp_c	37.0
VIT-000865	Mon Nov 02, 2026 11:23 AM	hr	80.0
VIT-000866	Mon Nov 02, 2026 11:23 AM	map	77.0
VIT-000867	Mon Nov 02, 2026 11:23 AM	gcs	15.0
VIT-000771	Mon Nov 02, 2026 07:23 PM	spo2	94.0	nasal cannula
VIT-000772	Mon Nov 02, 2026 07:23 PM	rr	20.0
VIT-000773	Mon Nov 02, 2026 07:23 PM	o2_lpm	2.0	nasal cannula
VIT-000868	Mon Nov 02, 2026 07:23 PM	temp_c	37.5
VIT-000869	Mon Nov 02, 2026 07:23 PM	hr	88.0
VIT-000870	Mon Nov 02, 2026 07:23 PM	map	78.0
VIT-000871	Mon Nov 02, 2026 07:23 PM	gcs	15.0
VIT-000774	Tue Nov 03, 2026 03:23 AM	spo2	94.0	nasal cannula
VIT-000775	Tue Nov 03, 2026 03:23 AM	rr	22.0
VIT-000776	Tue Nov 03, 2026 03:23 AM	o2_lpm	2.0	nasal cannula
VIT-000872	Tue Nov 03, 2026 03:23 AM	temp_c	36.9
VIT-000873	Tue Nov 03, 2026 03:23 AM	hr	69.0
VIT-000874	Tue Nov 03, 2026 03:23 AM	map	87.0
VIT-000875	Tue Nov 03, 2026 03:23 AM	gcs	15.0
VIT-000777	Tue Nov 03, 2026 11:23 AM	spo2	95.0	nasal cannula
VIT-000778	Tue Nov 03, 2026 11:23 AM	rr	20.0
VIT-000779	Tue Nov 03, 2026 11:23 AM	o2_lpm	2.0	nasal cannula
VIT-000876	Tue Nov 03, 2026 11:23 AM	temp_c	37.6
VIT-000877	Tue Nov 03, 2026 11:23 AM	hr	75.0
VIT-000878	Tue Nov 03, 2026 11:23 AM	map	90.0
VIT-000879	Tue Nov 03, 2026 11:23 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000043 10-26 12:03 piperacillin-tazobactam per protocol IV
MED-000044 10-27 05:00 cefepime per protocol IV
MED-000045 10-28 05:00 cefepime per protocol IV
ORD-000007 10-26 11:33 blood_culture: blood cultures x2

Notes

History and physical · DOC-000027 · Dr. Noor Halvorsen (resident) · Mon Oct 26, 2026 02:03 PM

Cited facts from this note (2)

bleeding_source: bleeding · cited p. 1, line 7 · confidence 0.50

Show source for bleeding_source

… sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, type 2 diabetes, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: 1. Sepsis: antibiotics, fluids. 2. Community-acquired pneumonia: ant …
infection_source: multifocal pneumonia · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… 26-10-26 11:03 Service: Hospital Medicine Attending: Dr. Cyrus Ellingham History of present illness: 54-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, type 2 diabetes, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: cl …

Source document DOC-000027: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Rosalind Yardley   MRN: MRN60745118   Admitted: 2026-10-26 11:03
Service: Hospital Medicine   Attending: Dr. Cyrus Ellingham

History of present illness: 54-year-old man admitted with sepsis. Chest x-ray shows multifocal pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD, type 2 diabetes, hypertension.
Denies bleeding, chest pain or fever.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Wound care note · DOC-000026 · Elena Jessup, RN, CWOCN (wound_nurse) · Tue Oct 27, 2026 02:03 PM

Cited facts from this note (2)

wound_site: sacral · cited p. 1, line 4 · confidence 0.95

Show source for wound_site

WOUND CARE NOTE Patient: Rosalind Yardley MRN: MRN60745118 Location: sacrum Stage: 2 (NPIAP) Description: partial-thickness skin loss with exposed dermis. Size: 3.7 x 1.8 x 0.2 cm. Plan: offloading every 2 hours, foam dressing, nutriti …
wound_stage: 2 · cited p. 1, line 5 · confidence 0.95

Show source for wound_stage

WOUND CARE NOTE Patient: Rosalind Yardley MRN: MRN60745118 Location: sacrum Stage: 2 (NPIAP) Description: partial-thickness skin loss with exposed dermis. Size: 3.7 x 1.8 x 0.2 cm. Plan: offloading every 2 hours, foam dressing, nutrition consul …

Source document DOC-000026: Wound care note (synthetic)

WOUND CARE NOTE
Patient: Rosalind Yardley   MRN: MRN60745118

Location: sacrum
Stage: 2 (NPIAP)
Description: partial-thickness skin loss with exposed dermis.
Size: 3.7 x 1.8 x 0.2 cm.
Plan: offloading every 2 hours, foam dressing, nutrition consult.

Nutrition assessment · DOC-000025 · Dario Larkspur, RD (dietitian) · Tue Oct 27, 2026 04:03 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN60745118 Context: acute illness Intake: eating 100% of meals. 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: well nourished; no malnutrition identified.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… e: eating 100% of meals. 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: well nourished; no malnutrition identified.
intake_pct: 100 · cited p. 1, line 5 · confidence 0.90

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Rosalind Yardley MRN: MRN60745118 Context: acute illness Intake: eating 100% of meals. 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

… acute illness Intake: eating 100% of meals. 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: well nourished; no malnutrition identified.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Rosalind Yardley MRN: MRN60745118 Context: acute illness Intake: eating 100% of meals. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle was …

Source document DOC-000025: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Rosalind Yardley   MRN: MRN60745118

Context: acute illness
Intake: eating 100% of meals.
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: well nourished; no malnutrition identified.

Progress note · DOC-000028 · Dr. Noor Halvorsen (resident) · Wed Oct 28, 2026 11:03 AM

Source document DOC-000028: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Rosalind Yardley   MRN: MRN60745118   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. Hypoxia: supplemental oxygen, wean as tolerated.
3. Sacral decubitus ulcer: wound care following, offloading.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000029 · Dr. Cyrus Ellingham (attending) · Tue Nov 03, 2026 02:09 PM

Source document DOC-000029: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Rosalind Yardley   MRN: MRN60745118
Admitted 2026-10-26; discharged 2026-11-03.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- hypoxia
- sacral decubitus ulcer
- GERD
- type 2 diabetes
- hypertension

Disposition: home with follow-up.