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-00039: Sana Pemberton

67F · MRN35397651 · Cardiology · admitted Mon Nov 09, 2026 04:36 PM · in hospital · attending Dr. Wes Merriweather · resident Dr. Keira Upfield · 157 cm, 45.5 kg

Documented diagnoses (current)

“malnutrition” · E46 Unspecified protein-calorie malnutrition
Principal: “acute on chronic diastolic heart failure” · I50.33 Acute on chronic diastolic (congestive) heart failure
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified

Illustrative grouping now: MS-DRG 292 Heart failure and shock with CC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 291.

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=1.033, t.ratio_s1=1.5, creat_rise_48h=0.02, 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=1.033, t.ratio_s3=3.0, creat_peak=0.94, 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=1.033, 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=0.02, 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 met

Specificity gap

Criteria support Acute blood loss anemia (D62); no corresponding diagnosis is documented.

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=8.98, t.hb_m=13, t.hb_f=12	true
derived: acute_fall	`hgb_drop >= t.drop_major or prbc_units >= t.prbc_major`	hgb_drop=3.2, t.drop_major=2.0, prbc_units=2, t.prbc_major=2	true
outcome: met	`bleeding_documented and anaemic and acute_fall`	bleeding_documented=True, anaemic=True, acute_fall=True	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=252, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=72.0, egfr_late=69.1	72.0
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=72.0, t.g2=60, egfr_late=69.1	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=72.0, 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=72.0, egfr_late=69.1, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=72.0, t.g2=60	true

Heart failure

Criteria met

No gap

Supported as documented (I50.33).

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=1479.0, t.bnp=100, ntprobnp_max=unknown, t.ntprobnp=300	true
derived: acute_count	`count(iv_loop_diuretic, np_elevated, new_o2)`	iv_loop_diuretic=True, np_elevated=True, new_o2=False	2
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=56.0, t.ref=40, t.pres=50	diastolic
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=56.0, 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=2, hf_history=True	acute on chronic
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=diastolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=diastolic, acuity=acute on chronic	false
outcome: dia_aoc	`hf_type == 'diastolic' and acuity == 'acute on chronic'`	hf_type=diastolic, acuity=acute on chronic	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

Clinical judgement required

Clinical judgement required: Only one consensus characteristic documented; two are required.

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=60.0, t.a_sev_intake_pct=50, intake_days=9.0, 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=60.0, t.a_mod_intake_pct=75, intake_days=9.0, t.a_mod_intake_days=7	true
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=60.0, t.c_intake_pct=75, intake_days=9.0, 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=60.0, t.c_intake_pct=75, intake_days=9.0, 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=60.0, 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=True, 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	1
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=1	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=1	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=67, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=18.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=18.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=18.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=18.5, t.c1=30	true

Pressure injury

Criteria met

Specificity gap

Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.

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=4	false
outcome: other_site	`wound_site != 'sacral'`	wound_site=sacral	false
outcome: stage1	`sacral and wound_stage == '1'`	sacral=True, wound_stage=4	false
outcome: stage2	`sacral and wound_stage == '2'`	sacral=True, wound_stage=4	false
outcome: stage3	`sacral and wound_stage == '3'`	sacral=True, wound_stage=4	false
outcome: stage4	`sacral and wound_stage == '4'`	sacral=True, wound_stage=4	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=37.5, 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=81.0, 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=10.23, t.wbc_hi=12, wbc_min_48h=6.44, 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=166.0	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=0.77	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=82.0	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=0.94	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=0.91	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 (29)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001340	Sat Nov 22, 2025 09:15 AM	creatinine	0.88 mg/dL
LAB-001341	Sun Aug 02, 2026 10:05 AM	creatinine	0.91 mg/dL
LAB-001342	Mon Nov 09, 2026 05:36 PM	creatinine	0.94 mg/dL
LAB-001347	Mon Nov 09, 2026 05:36 PM	bnp	1479.0 pg/mL
LAB-001348	Mon Nov 09, 2026 05:36 PM	sodium	136.0 mmol/L
LAB-001353	Mon Nov 09, 2026 05:36 PM	hemoglobin	12.13 g/dL
LAB-001358	Mon Nov 09, 2026 05:36 PM	wbc	6.54 x10^3/uL
LAB-001359	Mon Nov 09, 2026 05:36 PM	platelets	212.0 x10^3/uL
LAB-001368	Mon Nov 09, 2026 05:36 PM	bilirubin	0.77 mg/dL
LAB-001343	Tue Nov 10, 2026 05:00 AM	creatinine	0.94 mg/dL
LAB-001349	Tue Nov 10, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-001354	Tue Nov 10, 2026 05:00 AM	hemoglobin	10.24 g/dL
LAB-001360	Tue Nov 10, 2026 05:00 AM	wbc	10.23 x10^3/uL
LAB-001361	Tue Nov 10, 2026 05:00 AM	platelets	266.0 x10^3/uL
LAB-001344	Wed Nov 11, 2026 05:00 AM	creatinine	0.91 mg/dL
LAB-001350	Wed Nov 11, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001355	Wed Nov 11, 2026 05:00 AM	hemoglobin	8.98 g/dL
LAB-001362	Wed Nov 11, 2026 05:00 AM	wbc	6.44 x10^3/uL
LAB-001363	Wed Nov 11, 2026 05:00 AM	platelets	166.0 x10^3/uL
LAB-001345	Thu Nov 12, 2026 05:00 AM	creatinine	0.93 mg/dL
LAB-001351	Thu Nov 12, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-001356	Thu Nov 12, 2026 05:00 AM	hemoglobin	9.78 g/dL
LAB-001364	Thu Nov 12, 2026 05:00 AM	wbc	9.53 x10^3/uL
LAB-001365	Thu Nov 12, 2026 05:00 AM	platelets	280.0 x10^3/uL
LAB-001346	Fri Nov 13, 2026 05:00 AM	creatinine	0.91 mg/dL
LAB-001352	Fri Nov 13, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001357	Fri Nov 13, 2026 05:00 AM	hemoglobin	10.08 g/dL
LAB-001366	Fri Nov 13, 2026 05:00 AM	wbc	7.86 x10^3/uL
LAB-001367	Fri Nov 13, 2026 05:00 AM	platelets	289.0 x10^3/uL

Vitals (72)

Vitals
Row	When	Kind	Value	Detail
VIT-003864	Mon Nov 09, 2026 04:56 PM	spo2	97.0	room air
VIT-003865	Mon Nov 09, 2026 04:56 PM	rr	17.0
VIT-003888	Mon Nov 09, 2026 04:56 PM	temp_c	36.9
VIT-003889	Mon Nov 09, 2026 04:56 PM	hr	80.0
VIT-003890	Mon Nov 09, 2026 04:56 PM	map	88.0
VIT-003891	Mon Nov 09, 2026 04:56 PM	gcs	15.0
VIT-003866	Tue Nov 10, 2026 12:56 AM	spo2	99.0	room air
VIT-003867	Tue Nov 10, 2026 12:56 AM	rr	20.0
VIT-003892	Tue Nov 10, 2026 12:56 AM	temp_c	37.5
VIT-003893	Tue Nov 10, 2026 12:56 AM	hr	81.0
VIT-003894	Tue Nov 10, 2026 12:56 AM	map	88.0
VIT-003895	Tue Nov 10, 2026 12:56 AM	gcs	15.0
VIT-003868	Tue Nov 10, 2026 08:56 AM	spo2	96.0	room air
VIT-003869	Tue Nov 10, 2026 08:56 AM	rr	14.0
VIT-003896	Tue Nov 10, 2026 08:56 AM	temp_c	36.7
VIT-003897	Tue Nov 10, 2026 08:56 AM	hr	78.0
VIT-003898	Tue Nov 10, 2026 08:56 AM	map	83.0
VIT-003899	Tue Nov 10, 2026 08:56 AM	gcs	15.0
VIT-003870	Tue Nov 10, 2026 04:56 PM	spo2	94.0	room air
VIT-003871	Tue Nov 10, 2026 04:56 PM	rr	18.0
VIT-003900	Tue Nov 10, 2026 04:56 PM	temp_c	36.5
VIT-003901	Tue Nov 10, 2026 04:56 PM	hr	74.0
VIT-003902	Tue Nov 10, 2026 04:56 PM	map	87.0
VIT-003903	Tue Nov 10, 2026 04:56 PM	gcs	15.0
VIT-003872	Wed Nov 11, 2026 12:56 AM	spo2	99.0	room air
VIT-003873	Wed Nov 11, 2026 12:56 AM	rr	17.0
VIT-003904	Wed Nov 11, 2026 12:56 AM	temp_c	37.5
VIT-003905	Wed Nov 11, 2026 12:56 AM	hr	74.0
VIT-003906	Wed Nov 11, 2026 12:56 AM	map	82.0
VIT-003907	Wed Nov 11, 2026 12:56 AM	gcs	15.0
VIT-003874	Wed Nov 11, 2026 08:56 AM	spo2	99.0	room air
VIT-003875	Wed Nov 11, 2026 08:56 AM	rr	20.0
VIT-003908	Wed Nov 11, 2026 08:56 AM	temp_c	37.2
VIT-003909	Wed Nov 11, 2026 08:56 AM	hr	77.0
VIT-003910	Wed Nov 11, 2026 08:56 AM	map	91.0
VIT-003911	Wed Nov 11, 2026 08:56 AM	gcs	15.0
VIT-003876	Wed Nov 11, 2026 04:56 PM	spo2	97.0	room air
VIT-003877	Wed Nov 11, 2026 04:56 PM	rr	14.0
VIT-003912	Wed Nov 11, 2026 04:56 PM	temp_c	37.4
VIT-003913	Wed Nov 11, 2026 04:56 PM	hr	86.0
VIT-003914	Wed Nov 11, 2026 04:56 PM	map	74.0
VIT-003915	Wed Nov 11, 2026 04:56 PM	gcs	15.0
VIT-003878	Thu Nov 12, 2026 12:56 AM	spo2	97.0	room air
VIT-003879	Thu Nov 12, 2026 12:56 AM	rr	20.0
VIT-003916	Thu Nov 12, 2026 12:56 AM	temp_c	36.5
VIT-003917	Thu Nov 12, 2026 12:56 AM	hr	80.0
VIT-003918	Thu Nov 12, 2026 12:56 AM	map	76.0
VIT-003919	Thu Nov 12, 2026 12:56 AM	gcs	15.0
VIT-003880	Thu Nov 12, 2026 08:56 AM	spo2	99.0	room air
VIT-003881	Thu Nov 12, 2026 08:56 AM	rr	18.0
VIT-003920	Thu Nov 12, 2026 08:56 AM	temp_c	37.2
VIT-003921	Thu Nov 12, 2026 08:56 AM	hr	68.0
VIT-003922	Thu Nov 12, 2026 08:56 AM	map	91.0
VIT-003923	Thu Nov 12, 2026 08:56 AM	gcs	15.0
VIT-003882	Thu Nov 12, 2026 04:56 PM	spo2	99.0	room air
VIT-003883	Thu Nov 12, 2026 04:56 PM	rr	15.0
VIT-003924	Thu Nov 12, 2026 04:56 PM	temp_c	37.1
VIT-003925	Thu Nov 12, 2026 04:56 PM	hr	90.0
VIT-003926	Thu Nov 12, 2026 04:56 PM	map	78.0
VIT-003927	Thu Nov 12, 2026 04:56 PM	gcs	15.0
VIT-003884	Fri Nov 13, 2026 12:56 AM	spo2	94.0	room air
VIT-003885	Fri Nov 13, 2026 12:56 AM	rr	20.0
VIT-003928	Fri Nov 13, 2026 12:56 AM	temp_c	36.7
VIT-003929	Fri Nov 13, 2026 12:56 AM	hr	82.0
VIT-003930	Fri Nov 13, 2026 12:56 AM	map	81.0
VIT-003931	Fri Nov 13, 2026 12:56 AM	gcs	15.0
VIT-003886	Fri Nov 13, 2026 08:56 AM	spo2	98.0	room air
VIT-003887	Fri Nov 13, 2026 08:56 AM	rr	15.0
VIT-003932	Fri Nov 13, 2026 08:56 AM	temp_c	36.9
VIT-003933	Fri Nov 13, 2026 08:56 AM	hr	91.0
VIT-003934	Fri Nov 13, 2026 08:56 AM	map	84.0
VIT-003935	Fri Nov 13, 2026 08:56 AM	gcs	15.0

Medications, orders, echo, history (9)

MED-000141 11-09 08:00 furosemide 40 mg IV
MED-000142 11-09 20:00 furosemide 40 mg IV
MED-000143 11-10 08:00 furosemide 40 mg IV
MED-000144 11-10 20:00 furosemide 40 mg IV
MED-000145 11-11 08:00 furosemide 40 mg IV
MED-000146 11-11 20:00 furosemide 40 mg IV
ORD-000032 11-10 09:00 transfusion_prbc: transfuse PRBC
ECH-000017 2026-11-10 echo LVEF 56.0%
HX-000013 history: heart failure with preserved ejection fraction

Notes

History and physical · DOC-000131 · Dr. Keira Upfield (resident) · Mon Nov 09, 2026 07:36 PM

Cited facts from this note (1)

bleeding_source: bleeding from the surgical drain · cited p. 1, line 5 · confidence 0.85

Show source for bleeding_source

… ing: Dr. Wes Merriweather History of present illness: 67-year-old woman admitted with acute on chronic diastolic heart failure. Hospital course complicated by bleeding from the surgical drain. Past medical history: heart failure with preserved ejection fraction, hyperlipidemia. Review of systems otherwise negative. Exam: Lungs: scattered crackles at …

Source document DOC-000131: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Sana Pemberton   MRN: MRN35397651   Admitted: 2026-11-09 16:36
Service: Cardiology   Attending: Dr. Wes Merriweather

History of present illness: 67-year-old woman admitted with acute on chronic diastolic heart failure. Hospital course complicated by bleeding from the surgical drain.
Past medical history: heart failure with preserved ejection fraction, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Acute on chronic diastolic heart failure: diuresis and daily weights; monitor electrolytes.

Nutrition assessment · DOC-000129 · Vera Pemberton, RD (dietitian) · Tue Nov 10, 2026 07:36 PM

Cited facts from this note (6)

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

Show source for fat_loss

… : acute illness Intake: estimated energy intake 60% of needs for 9 days. 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: at risk; continue calorie counts.
fluid_accumulation: none · cited p. 1, line 7 · confidence 0.90

Show source for fluid_accumulation

… 60% of needs for 9 days. 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: at risk; continue calorie counts.
intake_days: 9 · cited p. 1, line 5 · confidence 0.95

Show source for intake_days

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Sana Pemberton MRN: MRN35397651 Context: acute illness Intake: estimated energy intake 60% of needs for 9 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation. …
intake_pct: 60 · cited p. 1, line 5 · confidence 0.95

Show source for intake_pct

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Sana Pemberton MRN: MRN35397651 Context: acute illness Intake: estimated energy intake 60% of needs for 9 days. 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

… ated energy intake 60% of needs for 9 days. 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: at risk; continue calorie counts.
nutrition_context: acute · cited p. 1, line 4 · confidence 0.95

Show source for nutrition_context

NUTRITION ASSESSMENT (Registered Dietitian) Patient: Sana Pemberton MRN: MRN35397651 Context: acute illness Intake: estimated energy intake 60% of needs for 9 days. Weight history: weight stable over the past 3 months. Nutrition-focused physical exam: no loss of subc …

Source document DOC-000129: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Sana Pemberton   MRN: MRN35397651

Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
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: at risk; continue calorie counts.

Wound care note · DOC-000130 · Elena Jessup, RN, CWOCN (wound_nurse) · Tue Nov 10, 2026 07:36 PM

Cited facts from this note (2)

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

Show source for wound_site

WOUND CARE NOTE Patient: Sana Pemberton MRN: MRN35397651 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 2.1 x 3.8 x 0.7 cm. Plan: offloading every 2 hours, foam dressing, nutrition …
wound_stage: 4 · cited p. 1, line 5 · confidence 0.95

Show source for wound_stage

WOUND CARE NOTE Patient: Sana Pemberton MRN: MRN35397651 Location: sacrum Stage: 4 (NPIAP) Description: full-thickness tissue loss with palpable bone. Size: 2.1 x 3.8 x 0.7 cm. Plan: offloading every 2 hours, foam dressing, nutrition consult.

Source document DOC-000130: Wound care note (synthetic)

WOUND CARE NOTE
Patient: Sana Pemberton   MRN: MRN35397651

Location: sacrum
Stage: 4 (NPIAP)
Description: full-thickness tissue loss with palpable bone.
Size: 2.1 x 3.8 x 0.7 cm.
Plan: offloading every 2 hours, foam dressing, nutrition consult.

Progress note · DOC-000132 · Dr. Keira Upfield (resident) · Fri Nov 13, 2026 02:55 PM · awaiting cosign

Source document DOC-000132: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Sana Pemberton   MRN: MRN35397651   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Acute on chronic diastolic heart failure: continue current management.
2. Malnutrition: dietitian following.

Resident: Dr. Keira Upfield   Attending cosign: pending