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-00024: Wes Elsworth

79F · MRN86698929 · Hospital Medicine · admitted Thu Oct 29, 2026 01:52 PM · discharged Tue Nov 03, 2026 02:48 PM · attending Dr. Gideon Zeller · resident Dr. Noor Halvorsen · 164 cm, 100.4 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“class 2 obesity” · E66.812 Obesity, class 2
“CKD stage 3a” · N18.31 Chronic kidney disease, stage 3a

Illustrative grouping now: MS-DRG 195 Simple pneumonia and pleurisy without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 193.

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=1.034, t.ratio_s1=1.5, creat_rise_48h=0.04, 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=1.034, 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=1.034, 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=0.04, 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=13.35, 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=13.35, anaemic=False	true

Chronic kidney disease

Clinical judgement required

Clinical judgement required: Pre-admission eGFR values fall on both sides of 60.

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=241, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=56.0, egfr_late=65.9	65.9
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=56.0, t.g2=60, egfr_late=65.9	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=65.9, 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=56.0, egfr_late=65.9, 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

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 met

No gap

Supported as documented (E66.812).

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=79, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=37.3, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=37.3, t.c2=35	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 met

Specificity gap

Criteria support Acute respiratory failure with hypoxia (J96.01); no corresponding diagnosis is documented.

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=57.0, pf_min=271	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=57.0, t.pao2=60, pf_min=271, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=30.0, t.rr_distress=28, wob_increased=True, adv_resp_support=False	true
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=True	false
outcome: met	`hypoxemia and distress`	hypoxemia=True, distress=True	true

Sepsis

Criteria met

No gap

Criteria support Sepsis (Sepsis-3); not documented (this rule does not prompt for an undocumented diagnosis).

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=37.4, t.t_hi=38, temp_min_48h=36.8, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=84.0, 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=30.0, 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=10.14, t.wbc_hi=12, wbc_min_48h=6.43, 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=True, sirs_wbc=False	1
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=271, adv_resp_support=False	2
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=218.0	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=0.71	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=75.0	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=0.92	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=0.89	0
derived: sofa_delta	`sofa_resp + sofa_coag + sofa_liver + sofa_cardio + sofa_cns + sofa_renal - sofa_renal_baseline`	sofa_resp=2, sofa_coag=0, sofa_liver=0, sofa_cardio=0, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	2
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=2, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=1, t.sirs_min=2	false
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=unknown, 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=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=True	true

Structured data

Labs (35)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000812	Tue Nov 18, 2025 09:15 AM	creatinine	1.02 mg/dL
LAB-000813	Sat Jul 18, 2026 10:05 AM	creatinine	0.89 mg/dL
LAB-000820	Thu Oct 29, 2026 02:17 PM	pao2	57.0 mmHg
LAB-000821	Thu Oct 29, 2026 02:17 PM	fio2	21.0 %
LAB-000814	Thu Oct 29, 2026 02:52 PM	creatinine	0.88 mg/dL
LAB-000822	Thu Oct 29, 2026 02:52 PM	sodium	140.0 mmol/L
LAB-000828	Thu Oct 29, 2026 02:52 PM	hemoglobin	13.64 g/dL
LAB-000834	Thu Oct 29, 2026 02:52 PM	wbc	9.63 x10^3/uL
LAB-000835	Thu Oct 29, 2026 02:52 PM	platelets	218.0 x10^3/uL
LAB-000846	Thu Oct 29, 2026 02:52 PM	bilirubin	0.71 mg/dL
LAB-000815	Fri Oct 30, 2026 05:00 AM	creatinine	0.89 mg/dL
LAB-000823	Fri Oct 30, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-000829	Fri Oct 30, 2026 05:00 AM	hemoglobin	13.35 g/dL
LAB-000836	Fri Oct 30, 2026 05:00 AM	wbc	10.14 x10^3/uL
LAB-000837	Fri Oct 30, 2026 05:00 AM	platelets	248.0 x10^3/uL
LAB-000816	Sat Oct 31, 2026 05:00 AM	creatinine	0.92 mg/dL
LAB-000824	Sat Oct 31, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-000830	Sat Oct 31, 2026 05:00 AM	hemoglobin	13.43 g/dL
LAB-000838	Sat Oct 31, 2026 05:00 AM	wbc	6.43 x10^3/uL
LAB-000839	Sat Oct 31, 2026 05:00 AM	platelets	281.0 x10^3/uL
LAB-000817	Sun Nov 01, 2026 05:00 AM	creatinine	0.89 mg/dL
LAB-000825	Sun Nov 01, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-000831	Sun Nov 01, 2026 05:00 AM	hemoglobin	13.72 g/dL
LAB-000840	Sun Nov 01, 2026 05:00 AM	wbc	8.08 x10^3/uL
LAB-000841	Sun Nov 01, 2026 05:00 AM	platelets	219.0 x10^3/uL
LAB-000818	Mon Nov 02, 2026 05:00 AM	creatinine	0.91 mg/dL
LAB-000826	Mon Nov 02, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-000832	Mon Nov 02, 2026 05:00 AM	hemoglobin	13.73 g/dL
LAB-000842	Mon Nov 02, 2026 05:00 AM	wbc	9.42 x10^3/uL
LAB-000843	Mon Nov 02, 2026 05:00 AM	platelets	221.0 x10^3/uL
LAB-000819	Tue Nov 03, 2026 05:00 AM	creatinine	0.92 mg/dL
LAB-000827	Tue Nov 03, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-000833	Tue Nov 03, 2026 05:00 AM	hemoglobin	13.45 g/dL
LAB-000844	Tue Nov 03, 2026 05:00 AM	wbc	7.67 x10^3/uL
LAB-000845	Tue Nov 03, 2026 05:00 AM	platelets	258.0 x10^3/uL

Vitals (112)

Vitals
Row	When	Kind	Value	Detail
VIT-002337	Thu Oct 29, 2026 02:12 PM	spo2	86.0	room air
VIT-002338	Thu Oct 29, 2026 02:12 PM	rr	30.0
VIT-002385	Thu Oct 29, 2026 02:12 PM	temp_c	37.4
VIT-002386	Thu Oct 29, 2026 02:12 PM	hr	81.0
VIT-002387	Thu Oct 29, 2026 02:12 PM	map	75.0
VIT-002388	Thu Oct 29, 2026 02:12 PM	gcs	15.0
VIT-002339	Thu Oct 29, 2026 02:22 PM	o2_lpm	5.0	nasal cannula
VIT-002340	Thu Oct 29, 2026 10:12 PM	spo2	92.0	nasal cannula
VIT-002341	Thu Oct 29, 2026 10:12 PM	rr	24.0
VIT-002342	Thu Oct 29, 2026 10:12 PM	o2_lpm	2.0	nasal cannula
VIT-002389	Thu Oct 29, 2026 10:12 PM	temp_c	36.9
VIT-002390	Thu Oct 29, 2026 10:12 PM	hr	81.0
VIT-002391	Thu Oct 29, 2026 10:12 PM	map	84.0
VIT-002392	Thu Oct 29, 2026 10:12 PM	gcs	15.0
VIT-002343	Fri Oct 30, 2026 06:12 AM	spo2	92.0	nasal cannula
VIT-002344	Fri Oct 30, 2026 06:12 AM	rr	21.0
VIT-002345	Fri Oct 30, 2026 06:12 AM	o2_lpm	2.0	nasal cannula
VIT-002393	Fri Oct 30, 2026 06:12 AM	temp_c	36.8
VIT-002394	Fri Oct 30, 2026 06:12 AM	hr	82.0
VIT-002395	Fri Oct 30, 2026 06:12 AM	map	83.0
VIT-002396	Fri Oct 30, 2026 06:12 AM	gcs	15.0
VIT-002346	Fri Oct 30, 2026 02:12 PM	spo2	95.0	nasal cannula
VIT-002347	Fri Oct 30, 2026 02:12 PM	rr	25.0
VIT-002348	Fri Oct 30, 2026 02:12 PM	o2_lpm	2.0	nasal cannula
VIT-002397	Fri Oct 30, 2026 02:12 PM	temp_c	37.1
VIT-002398	Fri Oct 30, 2026 02:12 PM	hr	84.0
VIT-002399	Fri Oct 30, 2026 02:12 PM	map	91.0
VIT-002400	Fri Oct 30, 2026 02:12 PM	gcs	15.0
VIT-002349	Fri Oct 30, 2026 10:12 PM	spo2	92.0	nasal cannula
VIT-002350	Fri Oct 30, 2026 10:12 PM	rr	24.0
VIT-002351	Fri Oct 30, 2026 10:12 PM	o2_lpm	2.0	nasal cannula
VIT-002401	Fri Oct 30, 2026 10:12 PM	temp_c	36.9
VIT-002402	Fri Oct 30, 2026 10:12 PM	hr	79.0
VIT-002403	Fri Oct 30, 2026 10:12 PM	map	78.0
VIT-002404	Fri Oct 30, 2026 10:12 PM	gcs	15.0
VIT-002352	Sat Oct 31, 2026 06:12 AM	spo2	95.0	nasal cannula
VIT-002353	Sat Oct 31, 2026 06:12 AM	rr	25.0
VIT-002354	Sat Oct 31, 2026 06:12 AM	o2_lpm	3.0	nasal cannula
VIT-002405	Sat Oct 31, 2026 06:12 AM	temp_c	37.0
VIT-002406	Sat Oct 31, 2026 06:12 AM	hr	79.0
VIT-002407	Sat Oct 31, 2026 06:12 AM	map	81.0
VIT-002408	Sat Oct 31, 2026 06:12 AM	gcs	15.0
VIT-002355	Sat Oct 31, 2026 02:12 PM	spo2	95.0	nasal cannula
VIT-002356	Sat Oct 31, 2026 02:12 PM	rr	20.0
VIT-002357	Sat Oct 31, 2026 02:12 PM	o2_lpm	4.0	nasal cannula
VIT-002409	Sat Oct 31, 2026 02:12 PM	temp_c	37.4
VIT-002410	Sat Oct 31, 2026 02:12 PM	hr	72.0
VIT-002411	Sat Oct 31, 2026 02:12 PM	map	90.0
VIT-002412	Sat Oct 31, 2026 02:12 PM	gcs	15.0
VIT-002358	Sat Oct 31, 2026 10:12 PM	spo2	95.0	nasal cannula
VIT-002359	Sat Oct 31, 2026 10:12 PM	rr	23.0
VIT-002360	Sat Oct 31, 2026 10:12 PM	o2_lpm	4.0	nasal cannula
VIT-002413	Sat Oct 31, 2026 10:12 PM	temp_c	37.1
VIT-002414	Sat Oct 31, 2026 10:12 PM	hr	90.0
VIT-002415	Sat Oct 31, 2026 10:12 PM	map	74.0
VIT-002416	Sat Oct 31, 2026 10:12 PM	gcs	15.0
VIT-002361	Sun Nov 01, 2026 06:12 AM	spo2	93.0	nasal cannula
VIT-002362	Sun Nov 01, 2026 06:12 AM	rr	21.0
VIT-002363	Sun Nov 01, 2026 06:12 AM	o2_lpm	2.0	nasal cannula
VIT-002417	Sun Nov 01, 2026 06:12 AM	temp_c	36.8
VIT-002418	Sun Nov 01, 2026 06:12 AM	hr	82.0
VIT-002419	Sun Nov 01, 2026 06:12 AM	map	85.0
VIT-002420	Sun Nov 01, 2026 06:12 AM	gcs	15.0
VIT-002364	Sun Nov 01, 2026 02:12 PM	spo2	95.0	nasal cannula
VIT-002365	Sun Nov 01, 2026 02:12 PM	rr	26.0
VIT-002366	Sun Nov 01, 2026 02:12 PM	o2_lpm	3.0	nasal cannula
VIT-002421	Sun Nov 01, 2026 02:12 PM	temp_c	37.3
VIT-002422	Sun Nov 01, 2026 02:12 PM	hr	77.0
VIT-002423	Sun Nov 01, 2026 02:12 PM	map	75.0
VIT-002424	Sun Nov 01, 2026 02:12 PM	gcs	15.0
VIT-002367	Sun Nov 01, 2026 10:12 PM	spo2	91.0	nasal cannula
VIT-002368	Sun Nov 01, 2026 10:12 PM	rr	22.0
VIT-002369	Sun Nov 01, 2026 10:12 PM	o2_lpm	3.0	nasal cannula
VIT-002425	Sun Nov 01, 2026 10:12 PM	temp_c	36.7
VIT-002426	Sun Nov 01, 2026 10:12 PM	hr	71.0
VIT-002427	Sun Nov 01, 2026 10:12 PM	map	92.0
VIT-002428	Sun Nov 01, 2026 10:12 PM	gcs	15.0
VIT-002370	Mon Nov 02, 2026 06:12 AM	spo2	91.0	nasal cannula
VIT-002371	Mon Nov 02, 2026 06:12 AM	rr	23.0
VIT-002372	Mon Nov 02, 2026 06:12 AM	o2_lpm	2.0	nasal cannula
VIT-002429	Mon Nov 02, 2026 06:12 AM	temp_c	37.3
VIT-002430	Mon Nov 02, 2026 06:12 AM	hr	89.0
VIT-002431	Mon Nov 02, 2026 06:12 AM	map	81.0
VIT-002432	Mon Nov 02, 2026 06:12 AM	gcs	15.0
VIT-002373	Mon Nov 02, 2026 02:12 PM	spo2	91.0	nasal cannula
VIT-002374	Mon Nov 02, 2026 02:12 PM	rr	22.0
VIT-002375	Mon Nov 02, 2026 02:12 PM	o2_lpm	4.0	nasal cannula
VIT-002433	Mon Nov 02, 2026 02:12 PM	temp_c	37.2
VIT-002434	Mon Nov 02, 2026 02:12 PM	hr	72.0
VIT-002435	Mon Nov 02, 2026 02:12 PM	map	80.0
VIT-002436	Mon Nov 02, 2026 02:12 PM	gcs	15.0
VIT-002376	Mon Nov 02, 2026 10:12 PM	spo2	94.0	nasal cannula
VIT-002377	Mon Nov 02, 2026 10:12 PM	rr	24.0
VIT-002378	Mon Nov 02, 2026 10:12 PM	o2_lpm	2.0	nasal cannula
VIT-002437	Mon Nov 02, 2026 10:12 PM	temp_c	36.8
VIT-002438	Mon Nov 02, 2026 10:12 PM	hr	69.0
VIT-002439	Mon Nov 02, 2026 10:12 PM	map	84.0
VIT-002440	Mon Nov 02, 2026 10:12 PM	gcs	15.0
VIT-002379	Tue Nov 03, 2026 06:12 AM	spo2	91.0	nasal cannula
VIT-002380	Tue Nov 03, 2026 06:12 AM	rr	24.0
VIT-002381	Tue Nov 03, 2026 06:12 AM	o2_lpm	3.0	nasal cannula
VIT-002441	Tue Nov 03, 2026 06:12 AM	temp_c	36.9
VIT-002442	Tue Nov 03, 2026 06:12 AM	hr	72.0
VIT-002443	Tue Nov 03, 2026 06:12 AM	map	92.0
VIT-002444	Tue Nov 03, 2026 06:12 AM	gcs	15.0
VIT-002382	Tue Nov 03, 2026 02:12 PM	spo2	92.0	nasal cannula
VIT-002383	Tue Nov 03, 2026 02:12 PM	rr	25.0
VIT-002384	Tue Nov 03, 2026 02:12 PM	o2_lpm	4.0	nasal cannula
VIT-002445	Tue Nov 03, 2026 02:12 PM	temp_c	37.1
VIT-002446	Tue Nov 03, 2026 02:12 PM	hr	84.0
VIT-002447	Tue Nov 03, 2026 02:12 PM	map	76.0
VIT-002448	Tue Nov 03, 2026 02:12 PM	gcs	15.0

Medications, orders, echo, history (4)

MED-000088 10-29 14:52 ceftriaxone per protocol IV
MED-000089 10-30 05:00 cefepime per protocol IV
MED-000090 10-31 05:00 cefepime per protocol IV
ORD-000019 10-29 14:22 blood_culture: blood cultures x2

Notes

History and physical · DOC-000078 · Dr. Noor Halvorsen (resident) · Thu Oct 29, 2026 04:52 PM

Cited facts from this note (2)

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

Show source for infection_source

… : Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 79-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: increased work of bre …
work_of_breathing: increased · cited p. 1, line 8 · confidence 0.90

Show source for work_of_breathing

… lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: none significant. Review of systems otherwise negative. Exam: Lungs: increased work of breathing with accessory muscle use. Assessment and plan: 1. Community-acquired pneumonia: antibiotics. 2. CKD stage 3a: renally dose medications.

Source document DOC-000078: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Wes Elsworth   MRN: MRN86698929   Admitted: 2026-10-29 13:52
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 79-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: increased work of breathing with accessory muscle use.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.
2. CKD stage 3a: renally dose medications.

Progress note · DOC-000079 · Dr. Noor Halvorsen (resident) · Sat Oct 31, 2026 01:52 PM

Source document DOC-000079: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Wes Elsworth   MRN: MRN86698929   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.
2. Class 2 obesity: counsel on weight.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000080 · Dr. Gideon Zeller (attending) · Tue Nov 03, 2026 02:48 PM

Source document DOC-000080: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Wes Elsworth   MRN: MRN86698929
Admitted 2026-10-29; discharged 2026-11-03.

Discharge diagnoses:
- community-acquired pneumonia
- class 2 obesity
- CKD stage 3a

Disposition: home with follow-up.