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-00013: Keira Holloway

78F · MRN90157324 · Hospital Medicine · admitted Fri Oct 30, 2026 05:31 PM · discharged Tue Nov 03, 2026 10:22 AM · attending Dr. Cyrus Ellingham · resident Dr. Greta Kowalczyk · 165 cm, 72.6 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

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=1.057, t.ratio_s1=1.5, creat_rise_48h=0.03, 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=1.057, t.ratio_s3=3.0, creat_peak=0.92, 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=1.057, 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=0.03, 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=F, hgb_nadir=12.69, 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=0.2, 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=0.2, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=12.69, 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=311, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=69.1, egfr_late=68.2	69.1
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=69.1, t.g2=60, egfr_late=68.2	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=69.1, 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=69.1, egfr_late=68.2, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=69.1, t.g2=60	true

Heart failure

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

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=False	0
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=0, 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=0	false

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

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

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=unknown, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	unknown
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=unknown, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	unknown
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=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=unknown, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	unknown
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=unknown, wt_loss_pct=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown	0
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=unknown, a_sev_intake=unknown, a_sev_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_sev_wt=unknown	unknown
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=unknown, a_sev_intake=unknown, a_mod_intake=unknown, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=unknown, muscle_loss=unknown, fluid=unknown, grip_reduced=unknown, c_sev_intake=unknown, c_mod_intake=unknown, c_sev_wt=unknown, c_mod_wt=unknown	unknown
outcome: severe	`n_severe >= 2`	n_severe=unknown	unknown
outcome: moderate	`n_moderate >= 2`	n_moderate=unknown	unknown
outcome: one_characteristic	`n_moderate == 1`	n_moderate=unknown	unknown
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=unknown, n_assessed=0	false

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=78, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=26.7, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=26.7, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=26.7, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=26.7, 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=19.0, 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 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=39.3, t.t_hi=38, temp_min_48h=38.6, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=117.0, 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=19.0, 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=17.9, t.wbc_hi=12, wbc_min_48h=15.08, 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=False, sirs_wbc=True	3
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=82.0	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=0.67	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=0.89	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=0.87	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=3, 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=2.88, 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 (29)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000428	Fri Sep 12, 2025 09:15 AM	creatinine	0.86 mg/dL
LAB-000429	Mon Jul 20, 2026 10:05 AM	creatinine	0.87 mg/dL
LAB-000430	Fri Oct 30, 2026 06:31 PM	creatinine	0.89 mg/dL
LAB-000435	Fri Oct 30, 2026 06:31 PM	sodium	140.0 mmol/L
LAB-000440	Fri Oct 30, 2026 06:31 PM	hemoglobin	12.74 g/dL
LAB-000445	Fri Oct 30, 2026 06:31 PM	wbc	16.12 x10^3/uL
LAB-000446	Fri Oct 30, 2026 06:31 PM	platelets	82.0 x10^3/uL
LAB-000455	Fri Oct 30, 2026 06:31 PM	bilirubin	0.67 mg/dL
LAB-000456	Fri Oct 30, 2026 06:31 PM	lactate	2.88 mmol/L
LAB-000431	Sat Oct 31, 2026 05:00 AM	creatinine	0.89 mg/dL
LAB-000436	Sat Oct 31, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-000441	Sat Oct 31, 2026 05:00 AM	hemoglobin	12.91 g/dL
LAB-000447	Sat Oct 31, 2026 05:00 AM	wbc	15.08 x10^3/uL
LAB-000448	Sat Oct 31, 2026 05:00 AM	platelets	82.0 x10^3/uL
LAB-000432	Sun Nov 01, 2026 05:00 AM	creatinine	0.89 mg/dL
LAB-000437	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000442	Sun Nov 01, 2026 05:00 AM	hemoglobin	12.85 g/dL
LAB-000449	Sun Nov 01, 2026 05:00 AM	wbc	17.9 x10^3/uL
LAB-000450	Sun Nov 01, 2026 05:00 AM	platelets	94.0 x10^3/uL
LAB-000433	Mon Nov 02, 2026 05:00 AM	creatinine	0.92 mg/dL
LAB-000438	Mon Nov 02, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000443	Mon Nov 02, 2026 05:00 AM	hemoglobin	12.76 g/dL
LAB-000451	Mon Nov 02, 2026 05:00 AM	wbc	6.26 x10^3/uL
LAB-000452	Mon Nov 02, 2026 05:00 AM	platelets	178.0 x10^3/uL
LAB-000434	Tue Nov 03, 2026 05:00 AM	creatinine	0.88 mg/dL
LAB-000439	Tue Nov 03, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000444	Tue Nov 03, 2026 05:00 AM	hemoglobin	12.69 g/dL
LAB-000453	Tue Nov 03, 2026 05:00 AM	wbc	7.29 x10^3/uL
LAB-000454	Tue Nov 03, 2026 05:00 AM	platelets	212.0 x10^3/uL

Vitals (72)

Vitals
Row	When	Kind	Value	Detail
VIT-001240	Fri Oct 30, 2026 05:51 PM	spo2	97.0	room air
VIT-001241	Fri Oct 30, 2026 05:51 PM	rr	15.0
VIT-001264	Fri Oct 30, 2026 05:51 PM	temp_c	39.1
VIT-001265	Fri Oct 30, 2026 05:51 PM	hr	107.0
VIT-001266	Fri Oct 30, 2026 05:51 PM	map	66.0
VIT-001267	Fri Oct 30, 2026 05:51 PM	gcs	15.0
VIT-001242	Sat Oct 31, 2026 01:51 AM	spo2	94.0	room air
VIT-001243	Sat Oct 31, 2026 01:51 AM	rr	19.0
VIT-001268	Sat Oct 31, 2026 01:51 AM	temp_c	38.9
VIT-001269	Sat Oct 31, 2026 01:51 AM	hr	106.0
VIT-001270	Sat Oct 31, 2026 01:51 AM	map	65.0
VIT-001271	Sat Oct 31, 2026 01:51 AM	gcs	15.0
VIT-001244	Sat Oct 31, 2026 09:51 AM	spo2	97.0	room air
VIT-001245	Sat Oct 31, 2026 09:51 AM	rr	16.0
VIT-001272	Sat Oct 31, 2026 09:51 AM	temp_c	38.6
VIT-001273	Sat Oct 31, 2026 09:51 AM	hr	117.0
VIT-001274	Sat Oct 31, 2026 09:51 AM	map	66.0
VIT-001275	Sat Oct 31, 2026 09:51 AM	gcs	15.0
VIT-001246	Sat Oct 31, 2026 05:51 PM	spo2	95.0	room air
VIT-001247	Sat Oct 31, 2026 05:51 PM	rr	15.0
VIT-001276	Sat Oct 31, 2026 05:51 PM	temp_c	39.0
VIT-001277	Sat Oct 31, 2026 05:51 PM	hr	102.0
VIT-001278	Sat Oct 31, 2026 05:51 PM	map	64.0
VIT-001279	Sat Oct 31, 2026 05:51 PM	gcs	15.0
VIT-001248	Sun Nov 01, 2026 01:51 AM	spo2	94.0	room air
VIT-001249	Sun Nov 01, 2026 01:51 AM	rr	15.0
VIT-001280	Sun Nov 01, 2026 01:51 AM	temp_c	39.3
VIT-001281	Sun Nov 01, 2026 01:51 AM	hr	113.0
VIT-001282	Sun Nov 01, 2026 01:51 AM	map	64.0
VIT-001283	Sun Nov 01, 2026 01:51 AM	gcs	15.0
VIT-001250	Sun Nov 01, 2026 09:51 AM	spo2	95.0	room air
VIT-001251	Sun Nov 01, 2026 09:51 AM	rr	19.0
VIT-001284	Sun Nov 01, 2026 09:51 AM	temp_c	38.9
VIT-001285	Sun Nov 01, 2026 09:51 AM	hr	111.0
VIT-001286	Sun Nov 01, 2026 09:51 AM	map	65.0
VIT-001287	Sun Nov 01, 2026 09:51 AM	gcs	15.0
VIT-001252	Sun Nov 01, 2026 05:51 PM	spo2	96.0	room air
VIT-001253	Sun Nov 01, 2026 05:51 PM	rr	17.0
VIT-001288	Sun Nov 01, 2026 05:51 PM	temp_c	37.3
VIT-001289	Sun Nov 01, 2026 05:51 PM	hr	76.0
VIT-001290	Sun Nov 01, 2026 05:51 PM	map	81.0
VIT-001291	Sun Nov 01, 2026 05:51 PM	gcs	15.0
VIT-001254	Mon Nov 02, 2026 01:51 AM	spo2	97.0	room air
VIT-001255	Mon Nov 02, 2026 01:51 AM	rr	16.0
VIT-001292	Mon Nov 02, 2026 01:51 AM	temp_c	37.4
VIT-001293	Mon Nov 02, 2026 01:51 AM	hr	76.0
VIT-001294	Mon Nov 02, 2026 01:51 AM	map	88.0
VIT-001295	Mon Nov 02, 2026 01:51 AM	gcs	15.0
VIT-001256	Mon Nov 02, 2026 09:51 AM	spo2	96.0	room air
VIT-001257	Mon Nov 02, 2026 09:51 AM	rr	19.0
VIT-001296	Mon Nov 02, 2026 09:51 AM	temp_c	36.9
VIT-001297	Mon Nov 02, 2026 09:51 AM	hr	70.0
VIT-001298	Mon Nov 02, 2026 09:51 AM	map	76.0
VIT-001299	Mon Nov 02, 2026 09:51 AM	gcs	15.0
VIT-001258	Mon Nov 02, 2026 05:51 PM	spo2	95.0	room air
VIT-001259	Mon Nov 02, 2026 05:51 PM	rr	15.0
VIT-001300	Mon Nov 02, 2026 05:51 PM	temp_c	36.8
VIT-001301	Mon Nov 02, 2026 05:51 PM	hr	81.0
VIT-001302	Mon Nov 02, 2026 05:51 PM	map	87.0
VIT-001303	Mon Nov 02, 2026 05:51 PM	gcs	15.0
VIT-001260	Tue Nov 03, 2026 01:51 AM	spo2	99.0	room air
VIT-001261	Tue Nov 03, 2026 01:51 AM	rr	15.0
VIT-001304	Tue Nov 03, 2026 01:51 AM	temp_c	37.5
VIT-001305	Tue Nov 03, 2026 01:51 AM	hr	81.0
VIT-001306	Tue Nov 03, 2026 01:51 AM	map	80.0
VIT-001307	Tue Nov 03, 2026 01:51 AM	gcs	15.0
VIT-001262	Tue Nov 03, 2026 09:51 AM	spo2	98.0	room air
VIT-001263	Tue Nov 03, 2026 09:51 AM	rr	19.0
VIT-001308	Tue Nov 03, 2026 09:51 AM	temp_c	37.4
VIT-001309	Tue Nov 03, 2026 09:51 AM	hr	77.0
VIT-001310	Tue Nov 03, 2026 09:51 AM	map	82.0
VIT-001311	Tue Nov 03, 2026 09:51 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000052 10-30 18:31 piperacillin-tazobactam per protocol IV
MED-000053 10-31 05:00 cefepime per protocol IV
MED-000054 11-01 05:00 piperacillin-tazobactam per protocol IV
ORD-000011 10-30 18:01 blood_culture: blood cultures x2

Notes

History and physical · DOC-000042 · Dr. Greta Kowalczyk (resident) · Fri Oct 30, 2026 08:31 PM

Cited facts from this note (1)

infection_source: left lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… -10-30 17:31 Service: Hospital Medicine Attending: Dr. Cyrus Ellingham History of present illness: 78-year-old woman admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: scattered crackle …

Source document DOC-000042: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Keira Holloway   MRN: MRN90157324   Admitted: 2026-10-30 17:31
Service: Hospital Medicine   Attending: Dr. Cyrus Ellingham

History of present illness: 78-year-old woman admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000043 · Dr. Greta Kowalczyk (resident) · Sun Nov 01, 2026 09:31 PM

Source document DOC-000043: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Keira Holloway   MRN: MRN90157324   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.

Resident: Dr. Greta Kowalczyk   Attending cosign: completed

Discharge summary · DOC-000044 · Dr. Cyrus Ellingham (attending) · Tue Nov 03, 2026 10:22 AM

Source document DOC-000044: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Keira Holloway   MRN: MRN90157324
Admitted 2026-10-30; discharged 2026-11-03.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- GERD
- hyperlipidemia

Disposition: home with follow-up.