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-00029: Marisol Abernath

78F · MRN96240807 · Hospital Medicine · admitted Sat Oct 31, 2026 01:59 PM · discharged Tue Nov 03, 2026 02:12 PM · attending Dr. Odette Galloway · resident Dr. Noor Halvorsen · 159 cm, 96.0 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“CKD stage 3b” · N18.32 Chronic kidney disease, stage 3b
“renal insufficiency” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

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 194.

Queries and events

No queries yet.

All rules applied

Rule Criteria Finding Outcome

Acute kidney injury

Criteria met

Specificity gap

Documented “renal insufficiency” (N28.9); criteria support the more specific Acute kidney injury (KDIGO stage 2) (N17.9).

Trace

Rule trace (rule aki v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: meets_definition	`creat_ratio >= t.ratio_s1 or creat_rise_48h >= t.rise_abs or coalesce(uo_hours_lt_0_5 >= t.uo_s1_h, false)`	creat_ratio=2.649, t.ratio_s1=1.5, creat_rise_48h=0.78, t.rise_abs=0.3, uo_hours_lt_0_5=18, t.uo_s1_h=6	true
derived: stage3	`meets_definition and (creat_ratio >= t.ratio_s3 or creat_peak >= t.scr_s3 or rrt_started or coalesce(uo_hours_lt_0_3 >= t.uo_s3_h, false) or coalesce(anuria_hours >= t.anuria_h, false))`	meets_definition=True, creat_ratio=2.649, t.ratio_s3=3.0, creat_peak=3.55, t.scr_s3=4.0, rrt_started=False, uo_hours_lt_0_3=0, t.uo_s3_h=24, anuria_hours=0, 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=2.649, t.ratio_s2=2.0, uo_hours_lt_0_5=18, t.uo_s2_h=12	true
derived: stage	`case(stage3, 3, stage2, 2, meets_definition, 1, 0)`	stage3=False, stage2=True, meets_definition=True	2
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.78, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=2, baseline_independent=True	true

Acute blood loss anaemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule blood_loss_anemia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: anaemic	`case(sex == 'M', hgb_nadir < t.hb_m, sex == 'F', hgb_nadir < t.hb_f, null)`	sex=F, hgb_nadir=13.4, 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=13.4, anaemic=False	true

Chronic kidney disease

Criteria met

No gap

Supported as documented (N18.32).

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=356, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=33.8, egfr_late=40.6	40.6
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=33.8, t.g2=60, egfr_late=40.6	true
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=40.6, t.g2=60, t.g3a=45, t.g3b=30, t.g4=15	G3b
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=True, egfr_early=33.8, egfr_late=40.6, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=40.6, t.g2=60	false
outcome: g3a	`category == 'G3a'`	category=G3b	false
outcome: g3b	`category == 'G3b'`	category=G3b	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 met

Specificity gap

Criteria support Obesity, class 2 (E66.812); 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=78, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=38.0, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=38.0, 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 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 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=36.5, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=77.0, 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=20.0, 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=8.4, t.wbc_hi=12, wbc_min_48h=7.06, 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=183.0	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=0.53	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=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=3.55	3
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=1.34	1
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=3, sofa_renal_baseline=1	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=0, 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 (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-000993	Mon Sep 15, 2025 09:15 AM	creatinine	1.56 mg/dL
LAB-000994	Sun Sep 06, 2026 10:05 AM	creatinine	1.34 mg/dL
LAB-000995	Sat Oct 31, 2026 02:59 PM	creatinine	2.77 mg/dL
LAB-000999	Sat Oct 31, 2026 02:59 PM	sodium	142.0 mmol/L
LAB-001003	Sat Oct 31, 2026 02:59 PM	hemoglobin	13.63 g/dL
LAB-001007	Sat Oct 31, 2026 02:59 PM	wbc	7.06 x10^3/uL
LAB-001008	Sat Oct 31, 2026 02:59 PM	platelets	183.0 x10^3/uL
LAB-001015	Sat Oct 31, 2026 02:59 PM	bilirubin	0.53 mg/dL
LAB-000996	Sun Nov 01, 2026 05:00 AM	creatinine	3.55 mg/dL
LAB-001000	Sun Nov 01, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001004	Sun Nov 01, 2026 05:00 AM	hemoglobin	13.4 g/dL
LAB-001009	Sun Nov 01, 2026 05:00 AM	wbc	8.4 x10^3/uL
LAB-001010	Sun Nov 01, 2026 05:00 AM	platelets	253.0 x10^3/uL
LAB-000997	Mon Nov 02, 2026 05:00 AM	creatinine	3.19 mg/dL
LAB-001001	Mon Nov 02, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001005	Mon Nov 02, 2026 05:00 AM	hemoglobin	13.66 g/dL
LAB-001011	Mon Nov 02, 2026 05:00 AM	wbc	7.59 x10^3/uL
LAB-001012	Mon Nov 02, 2026 05:00 AM	platelets	190.0 x10^3/uL
LAB-000998	Tue Nov 03, 2026 05:00 AM	creatinine	2.66 mg/dL
LAB-001002	Tue Nov 03, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001006	Tue Nov 03, 2026 05:00 AM	hemoglobin	13.49 g/dL
LAB-001013	Tue Nov 03, 2026 05:00 AM	wbc	8.28 x10^3/uL
LAB-001014	Tue Nov 03, 2026 05:00 AM	platelets	220.0 x10^3/uL

Vitals (62)

Vitals
Row	When	Kind	Value	Detail
VIT-002876	Sat Oct 31, 2026 02:19 PM	spo2	97.0	room air
VIT-002877	Sat Oct 31, 2026 02:19 PM	rr	15.0
VIT-002894	Sat Oct 31, 2026 02:19 PM	temp_c	37.2
VIT-002895	Sat Oct 31, 2026 02:19 PM	hr	69.0
VIT-002896	Sat Oct 31, 2026 02:19 PM	map	79.0
VIT-002897	Sat Oct 31, 2026 02:19 PM	gcs	15.0
VIT-002868	Sat Oct 31, 2026 07:59 PM	urine_ml_6h	633.6
VIT-002878	Sat Oct 31, 2026 10:19 PM	spo2	97.0	room air
VIT-002879	Sat Oct 31, 2026 10:19 PM	rr	14.0
VIT-002898	Sat Oct 31, 2026 10:19 PM	temp_c	36.5
VIT-002899	Sat Oct 31, 2026 10:19 PM	hr	71.0
VIT-002900	Sat Oct 31, 2026 10:19 PM	map	80.0
VIT-002901	Sat Oct 31, 2026 10:19 PM	gcs	15.0
VIT-002869	Sun Nov 01, 2026 01:59 AM	urine_ml_6h	241.9
VIT-002880	Sun Nov 01, 2026 06:19 AM	spo2	99.0	room air
VIT-002881	Sun Nov 01, 2026 06:19 AM	rr	20.0
VIT-002902	Sun Nov 01, 2026 06:19 AM	temp_c	37.2
VIT-002903	Sun Nov 01, 2026 06:19 AM	hr	75.0
VIT-002904	Sun Nov 01, 2026 06:19 AM	map	85.0
VIT-002905	Sun Nov 01, 2026 06:19 AM	gcs	15.0
VIT-002870	Sun Nov 01, 2026 07:59 AM	urine_ml_6h	241.9
VIT-002871	Sun Nov 01, 2026 01:59 PM	urine_ml_6h	241.9
VIT-002882	Sun Nov 01, 2026 02:19 PM	spo2	94.0	room air
VIT-002883	Sun Nov 01, 2026 02:19 PM	rr	19.0
VIT-002906	Sun Nov 01, 2026 02:19 PM	temp_c	37.4
VIT-002907	Sun Nov 01, 2026 02:19 PM	hr	77.0
VIT-002908	Sun Nov 01, 2026 02:19 PM	map	92.0
VIT-002909	Sun Nov 01, 2026 02:19 PM	gcs	15.0
VIT-002872	Sun Nov 01, 2026 07:59 PM	urine_ml_6h	633.6
VIT-002884	Sun Nov 01, 2026 10:19 PM	spo2	98.0	room air
VIT-002885	Sun Nov 01, 2026 10:19 PM	rr	15.0
VIT-002910	Sun Nov 01, 2026 10:19 PM	temp_c	36.7
VIT-002911	Sun Nov 01, 2026 10:19 PM	hr	71.0
VIT-002912	Sun Nov 01, 2026 10:19 PM	map	90.0
VIT-002913	Sun Nov 01, 2026 10:19 PM	gcs	15.0
VIT-002873	Mon Nov 02, 2026 01:59 AM	urine_ml_6h	633.6
VIT-002886	Mon Nov 02, 2026 06:19 AM	spo2	96.0	room air
VIT-002887	Mon Nov 02, 2026 06:19 AM	rr	19.0
VIT-002914	Mon Nov 02, 2026 06:19 AM	temp_c	36.8
VIT-002915	Mon Nov 02, 2026 06:19 AM	hr	73.0
VIT-002916	Mon Nov 02, 2026 06:19 AM	map	92.0
VIT-002917	Mon Nov 02, 2026 06:19 AM	gcs	15.0
VIT-002874	Mon Nov 02, 2026 07:59 AM	urine_ml_6h	633.6
VIT-002875	Mon Nov 02, 2026 01:59 PM	urine_ml_6h	633.6
VIT-002888	Mon Nov 02, 2026 02:19 PM	spo2	97.0	room air
VIT-002889	Mon Nov 02, 2026 02:19 PM	rr	14.0
VIT-002918	Mon Nov 02, 2026 02:19 PM	temp_c	37.1
VIT-002919	Mon Nov 02, 2026 02:19 PM	hr	85.0
VIT-002920	Mon Nov 02, 2026 02:19 PM	map	76.0
VIT-002921	Mon Nov 02, 2026 02:19 PM	gcs	15.0
VIT-002890	Mon Nov 02, 2026 10:19 PM	spo2	99.0	room air
VIT-002891	Mon Nov 02, 2026 10:19 PM	rr	18.0
VIT-002922	Mon Nov 02, 2026 10:19 PM	temp_c	36.9
VIT-002923	Mon Nov 02, 2026 10:19 PM	hr	90.0
VIT-002924	Mon Nov 02, 2026 10:19 PM	map	83.0
VIT-002925	Mon Nov 02, 2026 10:19 PM	gcs	15.0
VIT-002892	Tue Nov 03, 2026 06:19 AM	spo2	99.0	room air
VIT-002893	Tue Nov 03, 2026 06:19 AM	rr	20.0
VIT-002926	Tue Nov 03, 2026 06:19 AM	temp_c	36.9
VIT-002927	Tue Nov 03, 2026 06:19 AM	hr	68.0
VIT-002928	Tue Nov 03, 2026 06:19 AM	map	74.0
VIT-002929	Tue Nov 03, 2026 06:19 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000106 10-31 14:59 cefepime per protocol IV
MED-000107 11-01 05:00 ceftriaxone per protocol IV
MED-000108 11-02 05:00 ceftriaxone per protocol IV
ORD-000024 10-31 14:29 blood_culture: blood cultures x2

Notes

History and physical · DOC-000096 · Dr. Noor Halvorsen (resident) · Sat Oct 31, 2026 04:59 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

… Hospital Medicine Attending: Dr. Odette Galloway History of present illness: 78-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: scattered crackl …

Source document DOC-000096: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Marisol Abernath   MRN: MRN96240807   Admitted: 2026-10-31 13:59
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 78-year-old woman admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.
2. CKD stage 3b: renally dose medications.

Progress note · DOC-000097 · Dr. Noor Halvorsen (resident) · Mon Nov 02, 2026 02:59 PM

Source document DOC-000097: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Marisol Abernath   MRN: MRN96240807   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. Renal insufficiency: trend creatinine, avoid nephrotoxins.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000098 · Dr. Odette Galloway (attending) · Tue Nov 03, 2026 02:12 PM

Source document DOC-000098: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Marisol Abernath   MRN: MRN96240807
Admitted 2026-10-31; discharged 2026-11-03.

Discharge diagnoses:
- community-acquired pneumonia
- CKD stage 3b
- renal insufficiency
- GERD
- type 2 diabetes

Disposition: home with follow-up.