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-00052: Isaac Hartwell

70F · MRN92489419 · Hospital Medicine · admitted Mon Nov 02, 2026 01:52 PM · discharged Thu Nov 05, 2026 04:20 PM · attending Dr. Jalen Carrow · resident Dr. Camila Oyelaran · 165 cm, 75.9 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“hypertension” · I10 Essential (primary) hypertension
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications
“hyperlipidemia” · E78.5 Hyperlipidemia, 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 195.

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=1.057, t.ratio_s1=1.5, creat_rise_48h=0.0, 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=1.057, t.ratio_s3=3.0, creat_peak=0.74, 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=1.057, 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=0.0, 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=13.13, 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=0.0, 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=0.0, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.13, anaemic=False	true

Chronic kidney disease

Clinical judgement required

No gap

Not documented; egfr 60 or above; ckd g1-g2 requires markers of kidney damage, which are not assessed here.

Trace

Rule trace (rule ckd v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: chronic	`egfr_n >= 2 and egfr_span_days >= t.chronic_days`	egfr_n=2, egfr_span_days=269, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=91.4, egfr_late=93.0	93.0
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=91.4, t.g2=60, egfr_late=93.0	false
derived: category	`case(staging_egfr >= t.g2, 'G1-G2', staging_egfr >= t.g3a, 'G3a', staging_egfr >= t.g3b, 'G3b', staging_egfr >= t.g4, 'G4', 'G5')`	staging_egfr=93.0, 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=91.4, egfr_late=93.0, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=93.0, t.g2=60	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

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=70, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=27.9, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=27.9, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=27.9, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=27.9, 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

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=37.4, t.t_hi=38, temp_min_48h=36.6, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=87.0, 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=19.0, 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=7.78, 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=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=214.0	0
derived: sofa_liver	`coalesce(case(bili_max_48h >= 12, 4, bili_max_48h >= 6, 3, bili_max_48h >= 2, 2, bili_max_48h >= 1.2, 1, 0), 0)`	bili_max_48h=0.95	0
derived: sofa_cardio	`coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0)`	norepi_max_48h=0.0, map_min_48h=80.0	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=0.74	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=0.7	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=True, sofa_delta=0, t.sofa_delta=2	false
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=False, 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=False, sepsis2=False	false
outcome: sepsis3_only	`sepsis3`	sepsis3=False	false
outcome: definitions_disagree	`sepsis2`	sepsis2=False	false
outcome: neither	`true`	—	true

Structured data

Labs (23)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-001778	Thu Nov 27, 2025 09:15 AM	creatinine	0.71 mg/dL
LAB-001779	Mon Aug 24, 2026 10:05 AM	creatinine	0.7 mg/dL
LAB-001780	Mon Nov 02, 2026 02:52 PM	creatinine	0.74 mg/dL
LAB-001784	Mon Nov 02, 2026 02:52 PM	sodium	136.0 mmol/L
LAB-001788	Mon Nov 02, 2026 02:52 PM	hemoglobin	13.16 g/dL
LAB-001792	Mon Nov 02, 2026 02:52 PM	wbc	6.1 x10^3/uL
LAB-001793	Mon Nov 02, 2026 02:52 PM	platelets	214.0 x10^3/uL
LAB-001800	Mon Nov 02, 2026 02:52 PM	bilirubin	0.95 mg/dL
LAB-001781	Tue Nov 03, 2026 05:00 AM	creatinine	0.72 mg/dL
LAB-001785	Tue Nov 03, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-001789	Tue Nov 03, 2026 05:00 AM	hemoglobin	13.13 g/dL
LAB-001794	Tue Nov 03, 2026 05:00 AM	wbc	7.78 x10^3/uL
LAB-001795	Tue Nov 03, 2026 05:00 AM	platelets	229.0 x10^3/uL
LAB-001782	Wed Nov 04, 2026 05:00 AM	creatinine	0.72 mg/dL
LAB-001786	Wed Nov 04, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-001790	Wed Nov 04, 2026 05:00 AM	hemoglobin	13.31 g/dL
LAB-001796	Wed Nov 04, 2026 05:00 AM	wbc	5.92 x10^3/uL
LAB-001797	Wed Nov 04, 2026 05:00 AM	platelets	253.0 x10^3/uL
LAB-001783	Thu Nov 05, 2026 05:00 AM	creatinine	0.7 mg/dL
LAB-001787	Thu Nov 05, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-001791	Thu Nov 05, 2026 05:00 AM	hemoglobin	13.48 g/dL
LAB-001798	Thu Nov 05, 2026 05:00 AM	wbc	8.41 x10^3/uL
LAB-001799	Thu Nov 05, 2026 05:00 AM	platelets	176.0 x10^3/uL

Vitals (60)

Vitals
Row	When	Kind	Value	Detail
VIT-005125	Mon Nov 02, 2026 02:12 PM	spo2	99.0	room air
VIT-005126	Mon Nov 02, 2026 02:12 PM	rr	19.0
VIT-005145	Mon Nov 02, 2026 02:12 PM	temp_c	37.4
VIT-005146	Mon Nov 02, 2026 02:12 PM	hr	87.0
VIT-005147	Mon Nov 02, 2026 02:12 PM	map	83.0
VIT-005148	Mon Nov 02, 2026 02:12 PM	gcs	15.0
VIT-005127	Mon Nov 02, 2026 10:12 PM	spo2	97.0	room air
VIT-005128	Mon Nov 02, 2026 10:12 PM	rr	15.0
VIT-005149	Mon Nov 02, 2026 10:12 PM	temp_c	36.6
VIT-005150	Mon Nov 02, 2026 10:12 PM	hr	82.0
VIT-005151	Mon Nov 02, 2026 10:12 PM	map	81.0
VIT-005152	Mon Nov 02, 2026 10:12 PM	gcs	15.0
VIT-005129	Tue Nov 03, 2026 06:12 AM	spo2	96.0	room air
VIT-005130	Tue Nov 03, 2026 06:12 AM	rr	17.0
VIT-005153	Tue Nov 03, 2026 06:12 AM	temp_c	36.9
VIT-005154	Tue Nov 03, 2026 06:12 AM	hr	73.0
VIT-005155	Tue Nov 03, 2026 06:12 AM	map	90.0
VIT-005156	Tue Nov 03, 2026 06:12 AM	gcs	15.0
VIT-005131	Tue Nov 03, 2026 02:12 PM	spo2	95.0	room air
VIT-005132	Tue Nov 03, 2026 02:12 PM	rr	15.0
VIT-005157	Tue Nov 03, 2026 02:12 PM	temp_c	37.4
VIT-005158	Tue Nov 03, 2026 02:12 PM	hr	77.0
VIT-005159	Tue Nov 03, 2026 02:12 PM	map	82.0
VIT-005160	Tue Nov 03, 2026 02:12 PM	gcs	15.0
VIT-005133	Tue Nov 03, 2026 10:12 PM	spo2	94.0	room air
VIT-005134	Tue Nov 03, 2026 10:12 PM	rr	16.0
VIT-005161	Tue Nov 03, 2026 10:12 PM	temp_c	37.3
VIT-005162	Tue Nov 03, 2026 10:12 PM	hr	77.0
VIT-005163	Tue Nov 03, 2026 10:12 PM	map	80.0
VIT-005164	Tue Nov 03, 2026 10:12 PM	gcs	15.0
VIT-005135	Wed Nov 04, 2026 06:12 AM	spo2	95.0	room air
VIT-005136	Wed Nov 04, 2026 06:12 AM	rr	18.0
VIT-005165	Wed Nov 04, 2026 06:12 AM	temp_c	36.6
VIT-005166	Wed Nov 04, 2026 06:12 AM	hr	75.0
VIT-005167	Wed Nov 04, 2026 06:12 AM	map	89.0
VIT-005168	Wed Nov 04, 2026 06:12 AM	gcs	15.0
VIT-005137	Wed Nov 04, 2026 02:12 PM	spo2	94.0	room air
VIT-005138	Wed Nov 04, 2026 02:12 PM	rr	20.0
VIT-005169	Wed Nov 04, 2026 02:12 PM	temp_c	37.0
VIT-005170	Wed Nov 04, 2026 02:12 PM	hr	75.0
VIT-005171	Wed Nov 04, 2026 02:12 PM	map	89.0
VIT-005172	Wed Nov 04, 2026 02:12 PM	gcs	15.0
VIT-005139	Wed Nov 04, 2026 10:12 PM	spo2	98.0	room air
VIT-005140	Wed Nov 04, 2026 10:12 PM	rr	15.0
VIT-005173	Wed Nov 04, 2026 10:12 PM	temp_c	36.9
VIT-005174	Wed Nov 04, 2026 10:12 PM	hr	88.0
VIT-005175	Wed Nov 04, 2026 10:12 PM	map	78.0
VIT-005176	Wed Nov 04, 2026 10:12 PM	gcs	15.0
VIT-005141	Thu Nov 05, 2026 06:12 AM	spo2	97.0	room air
VIT-005142	Thu Nov 05, 2026 06:12 AM	rr	19.0
VIT-005177	Thu Nov 05, 2026 06:12 AM	temp_c	37.1
VIT-005178	Thu Nov 05, 2026 06:12 AM	hr	78.0
VIT-005179	Thu Nov 05, 2026 06:12 AM	map	88.0
VIT-005180	Thu Nov 05, 2026 06:12 AM	gcs	15.0
VIT-005143	Thu Nov 05, 2026 02:12 PM	spo2	98.0	room air
VIT-005144	Thu Nov 05, 2026 02:12 PM	rr	15.0
VIT-005181	Thu Nov 05, 2026 02:12 PM	temp_c	37.1
VIT-005182	Thu Nov 05, 2026 02:12 PM	hr	80.0
VIT-005183	Thu Nov 05, 2026 02:12 PM	map	80.0
VIT-005184	Thu Nov 05, 2026 02:12 PM	gcs	15.0

Medications, orders, echo, history (4)

MED-000188 11-02 14:52 piperacillin-tazobactam per protocol IV
MED-000189 11-03 05:00 piperacillin-tazobactam per protocol IV
MED-000190 11-04 05:00 ceftriaxone per protocol IV
ORD-000043 11-02 14:22 blood_culture: blood cultures x2

Notes

History and physical · DOC-000182 · Dr. Camila Oyelaran (resident) · Mon Nov 02, 2026 04:52 PM

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

… e: Hospital Medicine Attending: Dr. Jalen Carrow History of present illness: 70-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: hypertension, type 2 diabetes, hyperlipidemia. Review of systems otherwise negative. Exam: …

Source document DOC-000182: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Isaac Hartwell   MRN: MRN92489419   Admitted: 2026-11-02 13:52
Service: Hospital Medicine   Attending: Dr. Jalen Carrow

History of present illness: 70-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: hypertension, type 2 diabetes, hyperlipidemia.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000181 · Dario Larkspur, RD (dietitian) · Tue Nov 03, 2026 03:52 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN92489419 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: Isaac Hartwell MRN: MRN92489419 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: Isaac Hartwell MRN: MRN92489419 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-000181: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Isaac Hartwell   MRN: MRN92489419

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-000183 · Dr. Camila Oyelaran (resident) · Wed Nov 04, 2026 01:52 PM

Source document DOC-000183: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Isaac Hartwell   MRN: MRN92489419   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.

Resident: Dr. Camila Oyelaran   Attending cosign: completed

Discharge summary · DOC-000184 · Dr. Jalen Carrow (attending) · Thu Nov 05, 2026 04:20 PM

Source document DOC-000184: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Isaac Hartwell   MRN: MRN92489419
Admitted 2026-11-02; discharged 2026-11-05.

Discharge diagnoses:
- community-acquired pneumonia
- hypertension
- type 2 diabetes
- hyperlipidemia

Disposition: home with follow-up.