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-00045: Pilar Nakashima

60M · MRN10765791 · Hospital Medicine · admitted Thu Oct 29, 2026 08:12 AM · discharged Tue Nov 03, 2026 11:27 AM · attending Dr. Odette Galloway · resident Dr. Elena Nakashima · 167 cm, 65.5 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“renal insufficiency” · N28.9 Disorder of kidney and ureter, unspecified (renal insufficiency)
“hypoxemia” · R09.02 Hypoxemia
“anemia” · D64.9 Anemia, unspecified

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 1) (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=1.848, t.ratio_s1=1.5, creat_rise_48h=0.45, t.rise_abs=0.3, uo_hours_lt_0_5=unknown, 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=1.848, t.ratio_s3=3.0, creat_peak=2.07, 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=1.848, 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=True	1
derived: baseline_independent	`creat_baseline_known or creat_rise_48h >= t.rise_abs or rrt_started`	creat_baseline_known=True, creat_rise_48h=0.45, t.rise_abs=0.3, rrt_started=False	true
outcome: aki_staged	`stage >= 1 and baseline_independent`	stage=1, baseline_independent=True	true

Acute blood loss anaemia

Criteria met

No gap

Supported as documented (D64.9).

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=10.43, 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=0.1, 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=True, acute_fall=False	false
outcome: anaemia_only	`anaemic and hgb_drop < t.drop_min and prbc_units == 0`	anaemic=True, hgb_drop=0.1, t.drop_min=1.0, prbc_units=0	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=295, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=72.9, egfr_late=75.2	75.2
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=72.9, t.g2=60, egfr_late=75.2	false
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=75.2, 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=72.9, egfr_late=75.2, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=75.2, 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

Criteria not met

No gap

Not documented and not supported.

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=60, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.5, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

Rule trace (rule pressure_injury v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: sacral	`wound_site == 'sacral'`	wound_site=unknown	unknown
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=unknown	true

Acute respiratory failure

Clinical judgement required

Clinical judgement required: Hypoxaemia without a charted sign of respiratory distress.

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=87.0, 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=87.0, t.spo2_ra=88, pao2_min_ra=unknown, t.pao2=60, pf_min=unknown, t.pf=300	true
derived: distress	`coalesce(rr_max >= t.rr_distress, false) or coalesce(wob_increased, false) or adv_resp_support`	rr_max=23.0, t.rr_distress=28, wob_increased=unknown, adv_resp_support=False	false
outcome: chronic_baseline	`home_o2 and hypoxemia`	home_o2=False, hypoxemia=True	false
outcome: met	`hypoxemia and distress`	hypoxemia=True, distress=False	false
outcome: hypoxemia_only	`hypoxemia`	hypoxemia=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=37.2, t.t_hi=38, temp_min_48h=36.7, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=82.0, 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=23.0, 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=10.99, t.wbc_hi=12, wbc_min_48h=5.92, 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=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=205.0	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=0.85	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=83.0	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=2.07	2
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=1.12	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=2, 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 (33)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001537	Tue Oct 07, 2025 09:15 AM	creatinine	1.15 mg/dL
LAB-001538	Wed Jul 29, 2026 10:05 AM	creatinine	1.12 mg/dL
LAB-001539	Thu Oct 29, 2026 09:12 AM	creatinine	1.62 mg/dL
LAB-001545	Thu Oct 29, 2026 09:12 AM	sodium	136.0 mmol/L
LAB-001551	Thu Oct 29, 2026 09:12 AM	hemoglobin	10.5 g/dL
LAB-001557	Thu Oct 29, 2026 09:12 AM	wbc	5.92 x10^3/uL
LAB-001558	Thu Oct 29, 2026 09:12 AM	platelets	291.0 x10^3/uL
LAB-001569	Thu Oct 29, 2026 09:12 AM	bilirubin	0.85 mg/dL
LAB-001540	Fri Oct 30, 2026 05:00 AM	creatinine	2.07 mg/dL
LAB-001546	Fri Oct 30, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001552	Fri Oct 30, 2026 05:00 AM	hemoglobin	10.43 g/dL
LAB-001559	Fri Oct 30, 2026 05:00 AM	wbc	8.98 x10^3/uL
LAB-001560	Fri Oct 30, 2026 05:00 AM	platelets	205.0 x10^3/uL
LAB-001541	Sat Oct 31, 2026 05:00 AM	creatinine	1.87 mg/dL
LAB-001547	Sat Oct 31, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-001553	Sat Oct 31, 2026 05:00 AM	hemoglobin	10.73 g/dL
LAB-001561	Sat Oct 31, 2026 05:00 AM	wbc	10.99 x10^3/uL
LAB-001562	Sat Oct 31, 2026 05:00 AM	platelets	310.0 x10^3/uL
LAB-001542	Sun Nov 01, 2026 05:00 AM	creatinine	1.56 mg/dL
LAB-001548	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-001554	Sun Nov 01, 2026 05:00 AM	hemoglobin	10.55 g/dL
LAB-001563	Sun Nov 01, 2026 05:00 AM	wbc	9.34 x10^3/uL
LAB-001564	Sun Nov 01, 2026 05:00 AM	platelets	274.0 x10^3/uL
LAB-001543	Mon Nov 02, 2026 05:00 AM	creatinine	1.29 mg/dL
LAB-001549	Mon Nov 02, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-001555	Mon Nov 02, 2026 05:00 AM	hemoglobin	10.75 g/dL
LAB-001565	Mon Nov 02, 2026 05:00 AM	wbc	9.88 x10^3/uL
LAB-001566	Mon Nov 02, 2026 05:00 AM	platelets	265.0 x10^3/uL
LAB-001544	Tue Nov 03, 2026 05:00 AM	creatinine	1.18 mg/dL
LAB-001550	Tue Nov 03, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-001556	Tue Nov 03, 2026 05:00 AM	hemoglobin	10.65 g/dL
LAB-001567	Tue Nov 03, 2026 05:00 AM	wbc	10.94 x10^3/uL
LAB-001568	Tue Nov 03, 2026 05:00 AM	platelets	264.0 x10^3/uL

Vitals (111)

Vitals
Row	When	Kind	Value	Detail
VIT-004432	Thu Oct 29, 2026 08:32 AM	spo2	87.0	room air
VIT-004433	Thu Oct 29, 2026 08:32 AM	rr	20.0
VIT-004479	Thu Oct 29, 2026 08:32 AM	temp_c	36.8
VIT-004480	Thu Oct 29, 2026 08:32 AM	hr	82.0
VIT-004481	Thu Oct 29, 2026 08:32 AM	map	86.0
VIT-004482	Thu Oct 29, 2026 08:32 AM	gcs	15.0
VIT-004434	Thu Oct 29, 2026 04:32 PM	spo2	96.0	nasal cannula
VIT-004435	Thu Oct 29, 2026 04:32 PM	rr	23.0
VIT-004436	Thu Oct 29, 2026 04:32 PM	o2_lpm	2.0	nasal cannula
VIT-004483	Thu Oct 29, 2026 04:32 PM	temp_c	37.2
VIT-004484	Thu Oct 29, 2026 04:32 PM	hr	78.0
VIT-004485	Thu Oct 29, 2026 04:32 PM	map	92.0
VIT-004486	Thu Oct 29, 2026 04:32 PM	gcs	15.0
VIT-004437	Fri Oct 30, 2026 12:32 AM	spo2	92.0	nasal cannula
VIT-004438	Fri Oct 30, 2026 12:32 AM	rr	19.0
VIT-004439	Fri Oct 30, 2026 12:32 AM	o2_lpm	2.0	nasal cannula
VIT-004487	Fri Oct 30, 2026 12:32 AM	temp_c	37.2
VIT-004488	Fri Oct 30, 2026 12:32 AM	hr	81.0
VIT-004489	Fri Oct 30, 2026 12:32 AM	map	87.0
VIT-004490	Fri Oct 30, 2026 12:32 AM	gcs	15.0
VIT-004440	Fri Oct 30, 2026 08:32 AM	spo2	95.0	nasal cannula
VIT-004441	Fri Oct 30, 2026 08:32 AM	rr	22.0
VIT-004442	Fri Oct 30, 2026 08:32 AM	o2_lpm	2.0	nasal cannula
VIT-004491	Fri Oct 30, 2026 08:32 AM	temp_c	36.9
VIT-004492	Fri Oct 30, 2026 08:32 AM	hr	74.0
VIT-004493	Fri Oct 30, 2026 08:32 AM	map	88.0
VIT-004494	Fri Oct 30, 2026 08:32 AM	gcs	15.0
VIT-004443	Fri Oct 30, 2026 04:32 PM	spo2	92.0	nasal cannula
VIT-004444	Fri Oct 30, 2026 04:32 PM	rr	21.0
VIT-004445	Fri Oct 30, 2026 04:32 PM	o2_lpm	2.0	nasal cannula
VIT-004495	Fri Oct 30, 2026 04:32 PM	temp_c	36.7
VIT-004496	Fri Oct 30, 2026 04:32 PM	hr	80.0
VIT-004497	Fri Oct 30, 2026 04:32 PM	map	83.0
VIT-004498	Fri Oct 30, 2026 04:32 PM	gcs	15.0
VIT-004446	Sat Oct 31, 2026 12:32 AM	spo2	94.0	nasal cannula
VIT-004447	Sat Oct 31, 2026 12:32 AM	rr	23.0
VIT-004448	Sat Oct 31, 2026 12:32 AM	o2_lpm	2.0	nasal cannula
VIT-004499	Sat Oct 31, 2026 12:32 AM	temp_c	36.8
VIT-004500	Sat Oct 31, 2026 12:32 AM	hr	71.0
VIT-004501	Sat Oct 31, 2026 12:32 AM	map	90.0
VIT-004502	Sat Oct 31, 2026 12:32 AM	gcs	15.0
VIT-004449	Sat Oct 31, 2026 08:32 AM	spo2	95.0	nasal cannula
VIT-004450	Sat Oct 31, 2026 08:32 AM	rr	19.0
VIT-004451	Sat Oct 31, 2026 08:32 AM	o2_lpm	2.0	nasal cannula
VIT-004503	Sat Oct 31, 2026 08:32 AM	temp_c	37.6
VIT-004504	Sat Oct 31, 2026 08:32 AM	hr	79.0
VIT-004505	Sat Oct 31, 2026 08:32 AM	map	75.0
VIT-004506	Sat Oct 31, 2026 08:32 AM	gcs	15.0
VIT-004452	Sat Oct 31, 2026 04:32 PM	spo2	96.0	nasal cannula
VIT-004453	Sat Oct 31, 2026 04:32 PM	rr	19.0
VIT-004454	Sat Oct 31, 2026 04:32 PM	o2_lpm	2.0	nasal cannula
VIT-004507	Sat Oct 31, 2026 04:32 PM	temp_c	36.6
VIT-004508	Sat Oct 31, 2026 04:32 PM	hr	85.0
VIT-004509	Sat Oct 31, 2026 04:32 PM	map	75.0
VIT-004510	Sat Oct 31, 2026 04:32 PM	gcs	15.0
VIT-004455	Sun Nov 01, 2026 12:32 AM	spo2	96.0	nasal cannula
VIT-004456	Sun Nov 01, 2026 12:32 AM	rr	22.0
VIT-004457	Sun Nov 01, 2026 12:32 AM	o2_lpm	2.0	nasal cannula
VIT-004511	Sun Nov 01, 2026 12:32 AM	temp_c	36.9
VIT-004512	Sun Nov 01, 2026 12:32 AM	hr	89.0
VIT-004513	Sun Nov 01, 2026 12:32 AM	map	80.0
VIT-004514	Sun Nov 01, 2026 12:32 AM	gcs	15.0
VIT-004458	Sun Nov 01, 2026 08:32 AM	spo2	92.0	nasal cannula
VIT-004459	Sun Nov 01, 2026 08:32 AM	rr	20.0
VIT-004460	Sun Nov 01, 2026 08:32 AM	o2_lpm	2.0	nasal cannula
VIT-004515	Sun Nov 01, 2026 08:32 AM	temp_c	37.6
VIT-004516	Sun Nov 01, 2026 08:32 AM	hr	88.0
VIT-004517	Sun Nov 01, 2026 08:32 AM	map	88.0
VIT-004518	Sun Nov 01, 2026 08:32 AM	gcs	15.0
VIT-004461	Sun Nov 01, 2026 04:32 PM	spo2	95.0	nasal cannula
VIT-004462	Sun Nov 01, 2026 04:32 PM	rr	20.0
VIT-004463	Sun Nov 01, 2026 04:32 PM	o2_lpm	2.0	nasal cannula
VIT-004519	Sun Nov 01, 2026 04:32 PM	temp_c	37.0
VIT-004520	Sun Nov 01, 2026 04:32 PM	hr	70.0
VIT-004521	Sun Nov 01, 2026 04:32 PM	map	87.0
VIT-004522	Sun Nov 01, 2026 04:32 PM	gcs	15.0
VIT-004464	Mon Nov 02, 2026 12:32 AM	spo2	92.0	nasal cannula
VIT-004465	Mon Nov 02, 2026 12:32 AM	rr	19.0
VIT-004466	Mon Nov 02, 2026 12:32 AM	o2_lpm	2.0	nasal cannula
VIT-004523	Mon Nov 02, 2026 12:32 AM	temp_c	37.5
VIT-004524	Mon Nov 02, 2026 12:32 AM	hr	78.0
VIT-004525	Mon Nov 02, 2026 12:32 AM	map	80.0
VIT-004526	Mon Nov 02, 2026 12:32 AM	gcs	15.0
VIT-004467	Mon Nov 02, 2026 08:32 AM	spo2	92.0	nasal cannula
VIT-004468	Mon Nov 02, 2026 08:32 AM	rr	18.0
VIT-004469	Mon Nov 02, 2026 08:32 AM	o2_lpm	2.0	nasal cannula
VIT-004527	Mon Nov 02, 2026 08:32 AM	temp_c	37.5
VIT-004528	Mon Nov 02, 2026 08:32 AM	hr	74.0
VIT-004529	Mon Nov 02, 2026 08:32 AM	map	85.0
VIT-004530	Mon Nov 02, 2026 08:32 AM	gcs	15.0
VIT-004470	Mon Nov 02, 2026 04:32 PM	spo2	93.0	nasal cannula
VIT-004471	Mon Nov 02, 2026 04:32 PM	rr	20.0
VIT-004472	Mon Nov 02, 2026 04:32 PM	o2_lpm	2.0	nasal cannula
VIT-004531	Mon Nov 02, 2026 04:32 PM	temp_c	37.1
VIT-004532	Mon Nov 02, 2026 04:32 PM	hr	77.0
VIT-004533	Mon Nov 02, 2026 04:32 PM	map	86.0
VIT-004534	Mon Nov 02, 2026 04:32 PM	gcs	15.0
VIT-004473	Tue Nov 03, 2026 12:32 AM	spo2	93.0	nasal cannula
VIT-004474	Tue Nov 03, 2026 12:32 AM	rr	21.0
VIT-004475	Tue Nov 03, 2026 12:32 AM	o2_lpm	2.0	nasal cannula
VIT-004535	Tue Nov 03, 2026 12:32 AM	temp_c	36.7
VIT-004536	Tue Nov 03, 2026 12:32 AM	hr	88.0
VIT-004537	Tue Nov 03, 2026 12:32 AM	map	81.0
VIT-004538	Tue Nov 03, 2026 12:32 AM	gcs	15.0
VIT-004476	Tue Nov 03, 2026 08:32 AM	spo2	95.0	nasal cannula
VIT-004477	Tue Nov 03, 2026 08:32 AM	rr	21.0
VIT-004478	Tue Nov 03, 2026 08:32 AM	o2_lpm	2.0	nasal cannula
VIT-004539	Tue Nov 03, 2026 08:32 AM	temp_c	37.2
VIT-004540	Tue Nov 03, 2026 08:32 AM	hr	70.0
VIT-004541	Tue Nov 03, 2026 08:32 AM	map	90.0
VIT-004542	Tue Nov 03, 2026 08:32 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000164 10-29 09:12 piperacillin-tazobactam per protocol IV
MED-000165 10-30 05:00 piperacillin-tazobactam per protocol IV
MED-000166 10-31 05:00 ceftriaxone per protocol IV
ORD-000037 10-29 08:42 blood_culture: blood cultures x2

Notes

History and physical · DOC-000155 · Dr. Elena Nakashima (resident) · Thu Oct 29, 2026 11:12 AM

Cited facts from this note (1)

infection_source: right 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: 60-year-old man 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: clear to auscultation …

Source document DOC-000155: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Pilar Nakashima   MRN: MRN10765791   Admitted: 2026-10-29 08:12
Service: Hospital Medicine   Attending: Dr. Odette Galloway

History of present illness: 60-year-old man 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: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000154 · Vera Pemberton, RD (dietitian) · Fri Oct 30, 2026 12:12 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN10765791 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: Pilar Nakashima MRN: MRN10765791 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: Pilar Nakashima MRN: MRN10765791 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-000154: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Pilar Nakashima   MRN: MRN10765791

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.

Progress note · DOC-000156 · Dr. Elena Nakashima (resident) · Sat Oct 31, 2026 09:12 AM

Source document DOC-000156: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Pilar Nakashima   MRN: MRN10765791   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.
3. Hypoxemia: supplemental oxygen, wean as tolerated.
4. Anemia: trend hemoglobin.

Resident: Dr. Elena Nakashima   Attending cosign: completed

Discharge summary · DOC-000157 · Dr. Odette Galloway (attending) · Tue Nov 03, 2026 11:27 AM

Source document DOC-000157: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Pilar Nakashima   MRN: MRN10765791
Admitted 2026-10-29; discharged 2026-11-03.

Discharge diagnoses:
- community-acquired pneumonia
- renal insufficiency
- hypoxemia
- anemia

Disposition: home with follow-up.