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-00017: Zara Whitlock

70M · MRN32001162 · Pulmonology · admitted Sun Nov 08, 2026 05:21 PM · in hospital · attending Dr. Kenji Stavros · resident Dr. Noor Halvorsen · 170 cm, 57.9 kg

Documented diagnoses (current)

Principal: “COPD exacerbation” · J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
“malnourished” · E46 Unspecified protein-calorie malnutrition
“heart failure” · I50.9 Heart failure, unspecified
“sacral decubitus ulcer” · L89.159 Pressure ulcer of sacral region, unspecified stage
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 191 Chronic obstructive pulmonary disease with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 190.

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=1.05, t.ratio_s1=1.5, creat_rise_48h=0.06, 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=1.05, 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=1.05, 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=0.06, 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=13.49, 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=0.4, 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=0.4, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.49, 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=323, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=78.1, egfr_late=80.0	80.0
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=78.1, t.g2=60, egfr_late=80.0	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=80.0, 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=78.1, egfr_late=80.0, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=80.0, t.g2=60	true

Heart failure

Clinical judgement required

Clinical judgement required: 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=88.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	false
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, np_elevated=False, new_o2=False	1
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=26.0, t.ref=40, t.pres=50	systolic
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=26.0, 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=1, hf_history=False	unknown
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=systolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=systolic, acuity=unknown	unknown
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=systolic, acuity=unknown	unknown
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=systolic, acuity=unknown	unknown
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=systolic, acuity=unknown	false
outcome: dia_acute	`hf_type == 'diastolic' and acuity == 'acute'`	hf_type=systolic, acuity=unknown	false
outcome: dia_chronic	`hf_type == 'diastolic' and acuity == 'chronic'`	hf_type=systolic, acuity=unknown	false
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

Clinical validation gap

Documented “malnourished” (E46) but the criteria are not met: 4 characteristics assessed and none met.

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 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=70, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=20.0, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=20.0, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=20.0, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=20.0, t.c1=30	true

Pressure injury

Criteria met

Specificity gap

Documented “sacral decubitus ulcer” (L89.159); criteria support the more specific Pressure injury of sacral region, stage 3 (L89.153).

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=3	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=3	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=3	false
outcome: stage3	`sacral and wound_stage == '3'`	sacral=True, wound_stage=3	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=20.0, 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=37.6, 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=90.0, 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=11.0, t.wbc_hi=12, wbc_min_48h=6.97, 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=168.0	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=0.95	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=79.0	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=1.04	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=1.01	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=0, sofa_renal_baseline=0	0
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=False, sofa_delta=0, 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-000557	Wed Nov 12, 2025 09:15 AM	creatinine	1.03 mg/dL
LAB-000558	Fri Oct 02, 2026 10:05 AM	creatinine	1.01 mg/dL
LAB-000559	Sun Nov 08, 2026 06:21 PM	creatinine	1.04 mg/dL
LAB-000565	Sun Nov 08, 2026 06:21 PM	bnp	88.0 pg/mL
LAB-000566	Sun Nov 08, 2026 06:21 PM	sodium	136.0 mmol/L
LAB-000572	Sun Nov 08, 2026 06:21 PM	hemoglobin	13.91 g/dL
LAB-000578	Sun Nov 08, 2026 06:21 PM	wbc	8.94 x10^3/uL
LAB-000579	Sun Nov 08, 2026 06:21 PM	platelets	250.0 x10^3/uL
LAB-000590	Sun Nov 08, 2026 06:21 PM	bilirubin	0.95 mg/dL
LAB-000560	Mon Nov 09, 2026 05:00 AM	creatinine	1.01 mg/dL
LAB-000567	Mon Nov 09, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-000573	Mon Nov 09, 2026 05:00 AM	hemoglobin	13.71 g/dL
LAB-000580	Mon Nov 09, 2026 05:00 AM	wbc	11.0 x10^3/uL
LAB-000581	Mon Nov 09, 2026 05:00 AM	platelets	282.0 x10^3/uL
LAB-000561	Tue Nov 10, 2026 05:00 AM	creatinine	1.0 mg/dL
LAB-000568	Tue Nov 10, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000574	Tue Nov 10, 2026 05:00 AM	hemoglobin	13.85 g/dL
LAB-000582	Tue Nov 10, 2026 05:00 AM	wbc	6.97 x10^3/uL
LAB-000583	Tue Nov 10, 2026 05:00 AM	platelets	168.0 x10^3/uL
LAB-000562	Wed Nov 11, 2026 05:00 AM	creatinine	1.0 mg/dL
LAB-000569	Wed Nov 11, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-000575	Wed Nov 11, 2026 05:00 AM	hemoglobin	13.49 g/dL
LAB-000584	Wed Nov 11, 2026 05:00 AM	wbc	10.99 x10^3/uL
LAB-000585	Wed Nov 11, 2026 05:00 AM	platelets	302.0 x10^3/uL
LAB-000563	Thu Nov 12, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-000570	Thu Nov 12, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-000576	Thu Nov 12, 2026 05:00 AM	hemoglobin	13.84 g/dL
LAB-000586	Thu Nov 12, 2026 05:00 AM	wbc	8.08 x10^3/uL
LAB-000587	Thu Nov 12, 2026 05:00 AM	platelets	274.0 x10^3/uL
LAB-000564	Fri Nov 13, 2026 05:00 AM	creatinine	1.02 mg/dL
LAB-000571	Fri Nov 13, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-000577	Fri Nov 13, 2026 05:00 AM	hemoglobin	13.69 g/dL
LAB-000588	Fri Nov 13, 2026 05:00 AM	wbc	9.77 x10^3/uL
LAB-000589	Fri Nov 13, 2026 05:00 AM	platelets	199.0 x10^3/uL

Vitals (90)

Vitals
Row	When	Kind	Value	Detail
VIT-001582	Sun Nov 08, 2026 05:41 PM	spo2	94.0	room air
VIT-001583	Sun Nov 08, 2026 05:41 PM	rr	16.0
VIT-001612	Sun Nov 08, 2026 05:41 PM	temp_c	36.9
VIT-001613	Sun Nov 08, 2026 05:41 PM	hr	81.0
VIT-001614	Sun Nov 08, 2026 05:41 PM	map	82.0
VIT-001615	Sun Nov 08, 2026 05:41 PM	gcs	15.0
VIT-001584	Mon Nov 09, 2026 01:41 AM	spo2	98.0	room air
VIT-001585	Mon Nov 09, 2026 01:41 AM	rr	18.0
VIT-001616	Mon Nov 09, 2026 01:41 AM	temp_c	37.3
VIT-001617	Mon Nov 09, 2026 01:41 AM	hr	90.0
VIT-001618	Mon Nov 09, 2026 01:41 AM	map	89.0
VIT-001619	Mon Nov 09, 2026 01:41 AM	gcs	15.0
VIT-001586	Mon Nov 09, 2026 09:41 AM	spo2	99.0	room air
VIT-001587	Mon Nov 09, 2026 09:41 AM	rr	17.0
VIT-001620	Mon Nov 09, 2026 09:41 AM	temp_c	36.6
VIT-001621	Mon Nov 09, 2026 09:41 AM	hr	75.0
VIT-001622	Mon Nov 09, 2026 09:41 AM	map	91.0
VIT-001623	Mon Nov 09, 2026 09:41 AM	gcs	15.0
VIT-001588	Mon Nov 09, 2026 05:41 PM	spo2	96.0	room air
VIT-001589	Mon Nov 09, 2026 05:41 PM	rr	17.0
VIT-001624	Mon Nov 09, 2026 05:41 PM	temp_c	37.6
VIT-001625	Mon Nov 09, 2026 05:41 PM	hr	82.0
VIT-001626	Mon Nov 09, 2026 05:41 PM	map	80.0
VIT-001627	Mon Nov 09, 2026 05:41 PM	gcs	15.0
VIT-001590	Tue Nov 10, 2026 01:41 AM	spo2	96.0	room air
VIT-001591	Tue Nov 10, 2026 01:41 AM	rr	15.0
VIT-001628	Tue Nov 10, 2026 01:41 AM	temp_c	37.1
VIT-001629	Tue Nov 10, 2026 01:41 AM	hr	89.0
VIT-001630	Tue Nov 10, 2026 01:41 AM	map	79.0
VIT-001631	Tue Nov 10, 2026 01:41 AM	gcs	15.0
VIT-001592	Tue Nov 10, 2026 09:41 AM	spo2	95.0	room air
VIT-001593	Tue Nov 10, 2026 09:41 AM	rr	14.0
VIT-001632	Tue Nov 10, 2026 09:41 AM	temp_c	37.3
VIT-001633	Tue Nov 10, 2026 09:41 AM	hr	79.0
VIT-001634	Tue Nov 10, 2026 09:41 AM	map	79.0
VIT-001635	Tue Nov 10, 2026 09:41 AM	gcs	15.0
VIT-001594	Tue Nov 10, 2026 05:41 PM	spo2	94.0	room air
VIT-001595	Tue Nov 10, 2026 05:41 PM	rr	14.0
VIT-001636	Tue Nov 10, 2026 05:41 PM	temp_c	36.5
VIT-001637	Tue Nov 10, 2026 05:41 PM	hr	82.0
VIT-001638	Tue Nov 10, 2026 05:41 PM	map	92.0
VIT-001639	Tue Nov 10, 2026 05:41 PM	gcs	15.0
VIT-001596	Wed Nov 11, 2026 01:41 AM	spo2	98.0	room air
VIT-001597	Wed Nov 11, 2026 01:41 AM	rr	15.0
VIT-001640	Wed Nov 11, 2026 01:41 AM	temp_c	37.5
VIT-001641	Wed Nov 11, 2026 01:41 AM	hr	69.0
VIT-001642	Wed Nov 11, 2026 01:41 AM	map	90.0
VIT-001643	Wed Nov 11, 2026 01:41 AM	gcs	15.0
VIT-001598	Wed Nov 11, 2026 09:41 AM	spo2	94.0	room air
VIT-001599	Wed Nov 11, 2026 09:41 AM	rr	20.0
VIT-001644	Wed Nov 11, 2026 09:41 AM	temp_c	37.0
VIT-001645	Wed Nov 11, 2026 09:41 AM	hr	77.0
VIT-001646	Wed Nov 11, 2026 09:41 AM	map	84.0
VIT-001647	Wed Nov 11, 2026 09:41 AM	gcs	15.0
VIT-001600	Wed Nov 11, 2026 05:41 PM	spo2	97.0	room air
VIT-001601	Wed Nov 11, 2026 05:41 PM	rr	18.0
VIT-001648	Wed Nov 11, 2026 05:41 PM	temp_c	37.4
VIT-001649	Wed Nov 11, 2026 05:41 PM	hr	77.0
VIT-001650	Wed Nov 11, 2026 05:41 PM	map	85.0
VIT-001651	Wed Nov 11, 2026 05:41 PM	gcs	15.0
VIT-001602	Thu Nov 12, 2026 01:41 AM	spo2	95.0	room air
VIT-001603	Thu Nov 12, 2026 01:41 AM	rr	15.0
VIT-001652	Thu Nov 12, 2026 01:41 AM	temp_c	37.1
VIT-001653	Thu Nov 12, 2026 01:41 AM	hr	77.0
VIT-001654	Thu Nov 12, 2026 01:41 AM	map	86.0
VIT-001655	Thu Nov 12, 2026 01:41 AM	gcs	15.0
VIT-001604	Thu Nov 12, 2026 09:41 AM	spo2	96.0	room air
VIT-001605	Thu Nov 12, 2026 09:41 AM	rr	14.0
VIT-001656	Thu Nov 12, 2026 09:41 AM	temp_c	36.6
VIT-001657	Thu Nov 12, 2026 09:41 AM	hr	69.0
VIT-001658	Thu Nov 12, 2026 09:41 AM	map	74.0
VIT-001659	Thu Nov 12, 2026 09:41 AM	gcs	15.0
VIT-001606	Thu Nov 12, 2026 05:41 PM	spo2	97.0	room air
VIT-001607	Thu Nov 12, 2026 05:41 PM	rr	15.0
VIT-001660	Thu Nov 12, 2026 05:41 PM	temp_c	36.6
VIT-001661	Thu Nov 12, 2026 05:41 PM	hr	80.0
VIT-001662	Thu Nov 12, 2026 05:41 PM	map	79.0
VIT-001663	Thu Nov 12, 2026 05:41 PM	gcs	15.0
VIT-001608	Fri Nov 13, 2026 01:41 AM	spo2	96.0	room air
VIT-001609	Fri Nov 13, 2026 01:41 AM	rr	17.0
VIT-001664	Fri Nov 13, 2026 01:41 AM	temp_c	37.5
VIT-001665	Fri Nov 13, 2026 01:41 AM	hr	68.0
VIT-001666	Fri Nov 13, 2026 01:41 AM	map	76.0
VIT-001667	Fri Nov 13, 2026 01:41 AM	gcs	15.0
VIT-001610	Fri Nov 13, 2026 09:41 AM	spo2	96.0	room air
VIT-001611	Fri Nov 13, 2026 09:41 AM	rr	20.0
VIT-001668	Fri Nov 13, 2026 09:41 AM	temp_c	37.1
VIT-001669	Fri Nov 13, 2026 09:41 AM	hr	89.0
VIT-001670	Fri Nov 13, 2026 09:41 AM	map	85.0
VIT-001671	Fri Nov 13, 2026 09:41 AM	gcs	15.0

Medications, orders, echo, history (2)

MED-000064 11-08 20:21 furosemide 40 mg IV
ECH-000007 2026-11-09 echo LVEF 26.0%

Notes

History and physical · DOC-000056 · Dr. Noor Halvorsen (resident) · Sun Nov 08, 2026 08:21 PM

Cited facts from this note (1)

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

Show source for bleeding_source

… ng: Dr. Kenji Stavros History of present illness: 70-year-old man admitted with COPD exacerbation. Past medical history: hyperlipidemia, hypertension. Denies bleeding, chest pain or fever. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: 1. COPD exacerbation: bronchodilators and steroids.

Source document DOC-000056: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Zara Whitlock   MRN: MRN32001162   Admitted: 2026-11-08 17:21
Service: Pulmonology   Attending: Dr. Kenji Stavros

History of present illness: 70-year-old man admitted with COPD exacerbation. 
Past medical history: hyperlipidemia, hypertension.
Denies bleeding, chest pain or fever.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. COPD exacerbation: bronchodilators and steroids.

Nutrition assessment · DOC-000054 · Vera Pemberton, RD (dietitian) · Mon Nov 09, 2026 08:21 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN32001162 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: Zara Whitlock MRN: MRN32001162 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: Zara Whitlock MRN: MRN32001162 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-000054: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Zara Whitlock   MRN: MRN32001162

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.

Wound care note · DOC-000055 · Ines Ingram, RN, CWOCN (wound_nurse) · Tue Nov 10, 2026 01:21 AM

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: Zara Whitlock MRN: MRN32001162 Location: sacrum Stage: 3 (NPIAP) Description: full-thickness skin loss, adipose visible, no tendon or bone. Size: 2.4 x 2.9 x 0.6 cm. Plan: offloading every 2 hours, foam dres …
wound_stage: 3 · cited p. 1, line 5 · confidence 0.95

Show source for wound_stage

WOUND CARE NOTE Patient: Zara Whitlock MRN: MRN32001162 Location: sacrum Stage: 3 (NPIAP) Description: full-thickness skin loss, adipose visible, no tendon or bone. Size: 2.4 x 2.9 x 0.6 cm. Plan: offloading every 2 hours, foam dressing, nut …

Source document DOC-000055: Wound care note (synthetic)

WOUND CARE NOTE
Patient: Zara Whitlock   MRN: MRN32001162

Location: sacrum
Stage: 3 (NPIAP)
Description: full-thickness skin loss, adipose visible, no tendon or bone.
Size: 2.4 x 2.9 x 0.6 cm.
Plan: offloading every 2 hours, foam dressing, nutrition consult.

Progress note · DOC-000057 · Dr. Noor Halvorsen (resident) · Fri Nov 13, 2026 01:55 PM · awaiting cosign

Source document DOC-000057: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Zara Whitlock   MRN: MRN32001162   Hospital day 5

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. COPD exacerbation: continue current management.
2. Malnourished: dietitian following.
3. Heart failure: diuresis and daily weights; monitor electrolytes.
4. Sacral decubitus ulcer: wound care following, offloading.

Resident: Dr. Noor Halvorsen   Attending cosign: pending