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-00085: Camila Upfield

76M · MRN78105176 · Hospital Medicine · admitted Sat Oct 31, 2026 07:25 PM · discharged Tue Nov 03, 2026 10:16 AM · attending Dr. Wes Merriweather · resident Dr. Noor Halvorsen · 175 cm, 71.7 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“urinary tract infection” · N39.0 Urinary tract infection, site not specified
“HFrEF” · I50.20 Unspecified systolic (congestive) heart failure
“acute hypoxic respiratory failure” · J96.01 Acute respiratory failure with hypoxia
“stage 4 sacral pressure ulcer” · L89.154 Pressure ulcer of sacral region, stage 4
“hypertension” · I10 Essential (primary) hypertension

Illustrative grouping now: MS-DRG 871 Septicemia or severe sepsis without MV >96 hours with MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 871.

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=1.054, t.ratio_s1=1.5, creat_rise_48h=0.06, 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=1.054, t.ratio_s3=3.0, creat_peak=1.18, 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=1.054, 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=0.06, 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=M, hgb_nadir=14.5, 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=0.4, 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=0.4, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.5, 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=317, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=68.8, egfr_late=68.1	68.8
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=68.8, t.g2=60, egfr_late=68.1	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=68.8, 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=68.8, egfr_late=68.1, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=68.8, t.g2=60	true

Heart failure

Criteria met

Specificity gap

Documented “HFrEF” (I50.20); criteria support the more specific Acute systolic (HFrEF) heart failure (I50.21).

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=1013.0, 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=True	3
derived: hf_type	`case(lvef <= t.ref, 'systolic', lvef >= t.pres, 'diastolic', 'midrange')`	lvef=29.0, t.ref=40, t.pres=50	systolic
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=29.0, 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=3, hf_history=False	acute
outcome: improved_ef	`improved`	improved=False	false
outcome: midrange	`hf_type == 'midrange'`	hf_type=systolic	false
outcome: sys_aoc	`hf_type == 'systolic' and acuity == 'acute on chronic'`	hf_type=systolic, acuity=acute	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=systolic, acuity=acute	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=137.0, 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=137.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=137.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=137.0, 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 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=76, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.4, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.4, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.4, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.4, 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=sacral	true
outcome: no_wound_note	`not present(wound_stage)`	wound_stage=unknown	true

Acute respiratory failure

Criteria not met

Clinical validation gap

Documented “acute hypoxic respiratory failure” (J96.01) but the criteria are not met: No hypoxaemia on room air (lowest SpO2 94%), oxygen no more than 2 L/min, no advanced support.

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=21.0, 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=2.0, t.o2_low=2, adv_resp_support=False	true

Sepsis

Criteria met

No gap

Supported as documented (A41.9).

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=39.3, t.t_hi=38, temp_min_48h=38.6, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=114.0, t.hr=90	true
derived: sirs_rr	`coalesce(rr_max_48h > t.rr, false) or coalesce(paco2_min_48h < t.paco2, false)`	rr_max_48h=21.0, 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=16.99, t.wbc_hi=12, wbc_min_48h=14.63, t.wbc_lo=4, bands_max_48h=unknown, t.bands=10	true
derived: sirs_count	`count(sirs_temp, sirs_hr, sirs_rr, sirs_wbc)`	sirs_temp=True, sirs_hr=True, sirs_rr=True, sirs_wbc=True	4
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=85.0	2
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=0.59	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=66.0	1
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=1.18	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=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=2, sofa_liver=0, sofa_cardio=1, sofa_cns=0, sofa_renal=0, sofa_renal_baseline=0	3
derived: sepsis3	`infection_documented and sofa_delta >= t.sofa_delta`	infection_documented=True, sofa_delta=3, t.sofa_delta=2	true
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=True, sirs_count=4, t.sirs_min=2	true
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=2.71, 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=True	true

Structured data

Labs (25)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002864	Mon Sep 08, 2025 09:15 AM	creatinine	1.11 mg/dL
LAB-002865	Wed Jul 22, 2026 10:05 AM	creatinine	1.12 mg/dL
LAB-002866	Sat Oct 31, 2026 08:25 PM	creatinine	1.12 mg/dL
LAB-002870	Sat Oct 31, 2026 08:25 PM	bnp	1013.0 pg/mL
LAB-002871	Sat Oct 31, 2026 08:25 PM	sodium	137.0 mmol/L
LAB-002875	Sat Oct 31, 2026 08:25 PM	hemoglobin	14.93 g/dL
LAB-002879	Sat Oct 31, 2026 08:25 PM	wbc	14.63 x10^3/uL
LAB-002880	Sat Oct 31, 2026 08:25 PM	platelets	88.0 x10^3/uL
LAB-002887	Sat Oct 31, 2026 08:25 PM	bilirubin	0.59 mg/dL
LAB-002888	Sat Oct 31, 2026 08:25 PM	lactate	2.71 mmol/L
LAB-002867	Sun Nov 01, 2026 05:00 AM	creatinine	1.18 mg/dL
LAB-002872	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002876	Sun Nov 01, 2026 05:00 AM	hemoglobin	14.52 g/dL
LAB-002881	Sun Nov 01, 2026 05:00 AM	wbc	14.65 x10^3/uL
LAB-002882	Sun Nov 01, 2026 05:00 AM	platelets	85.0 x10^3/uL
LAB-002868	Mon Nov 02, 2026 05:00 AM	creatinine	1.16 mg/dL
LAB-002873	Mon Nov 02, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002877	Mon Nov 02, 2026 05:00 AM	hemoglobin	14.5 g/dL
LAB-002883	Mon Nov 02, 2026 05:00 AM	wbc	16.99 x10^3/uL
LAB-002884	Mon Nov 02, 2026 05:00 AM	platelets	94.0 x10^3/uL
LAB-002869	Tue Nov 03, 2026 05:00 AM	creatinine	1.13 mg/dL
LAB-002874	Tue Nov 03, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-002878	Tue Nov 03, 2026 05:00 AM	hemoglobin	14.59 g/dL
LAB-002885	Tue Nov 03, 2026 05:00 AM	wbc	10.57 x10^3/uL
LAB-002886	Tue Nov 03, 2026 05:00 AM	platelets	206.0 x10^3/uL

Vitals (50)

Vitals
Row	When	Kind	Value	Detail
VIT-008263	Sat Oct 31, 2026 07:45 PM	spo2	94.0	room air
VIT-008264	Sat Oct 31, 2026 07:45 PM	rr	19.0
VIT-008281	Sat Oct 31, 2026 07:45 PM	temp_c	38.9
VIT-008282	Sat Oct 31, 2026 07:45 PM	hr	114.0
VIT-008283	Sat Oct 31, 2026 07:45 PM	map	68.0
VIT-008284	Sat Oct 31, 2026 07:45 PM	gcs	15.0
VIT-008265	Sun Nov 01, 2026 03:45 AM	spo2	96.0	room air
VIT-008266	Sun Nov 01, 2026 03:45 AM	rr	17.0
VIT-008285	Sun Nov 01, 2026 03:45 AM	temp_c	38.6
VIT-008286	Sun Nov 01, 2026 03:45 AM	hr	113.0
VIT-008287	Sun Nov 01, 2026 03:45 AM	map	68.0
VIT-008288	Sun Nov 01, 2026 03:45 AM	gcs	15.0
VIT-008267	Sun Nov 01, 2026 03:50 AM	o2_lpm	2.0	nasal cannula
VIT-008268	Sun Nov 01, 2026 11:45 AM	spo2	95.0	room air
VIT-008269	Sun Nov 01, 2026 11:45 AM	rr	20.0
VIT-008289	Sun Nov 01, 2026 11:45 AM	temp_c	38.8
VIT-008290	Sun Nov 01, 2026 11:45 AM	hr	110.0
VIT-008291	Sun Nov 01, 2026 11:45 AM	map	68.0
VIT-008292	Sun Nov 01, 2026 11:45 AM	gcs	15.0
VIT-008270	Sun Nov 01, 2026 11:50 AM	o2_lpm	2.0	nasal cannula
VIT-008271	Sun Nov 01, 2026 07:45 PM	spo2	97.0	room air
VIT-008272	Sun Nov 01, 2026 07:45 PM	rr	21.0
VIT-008293	Sun Nov 01, 2026 07:45 PM	temp_c	38.8
VIT-008294	Sun Nov 01, 2026 07:45 PM	hr	104.0
VIT-008295	Sun Nov 01, 2026 07:45 PM	map	66.0
VIT-008296	Sun Nov 01, 2026 07:45 PM	gcs	15.0
VIT-008273	Mon Nov 02, 2026 03:45 AM	spo2	95.0	room air
VIT-008274	Mon Nov 02, 2026 03:45 AM	rr	18.0
VIT-008297	Mon Nov 02, 2026 03:45 AM	temp_c	38.8
VIT-008298	Mon Nov 02, 2026 03:45 AM	hr	112.0
VIT-008299	Mon Nov 02, 2026 03:45 AM	map	66.0
VIT-008300	Mon Nov 02, 2026 03:45 AM	gcs	15.0
VIT-008275	Mon Nov 02, 2026 11:45 AM	spo2	97.0	room air
VIT-008276	Mon Nov 02, 2026 11:45 AM	rr	19.0
VIT-008301	Mon Nov 02, 2026 11:45 AM	temp_c	39.3
VIT-008302	Mon Nov 02, 2026 11:45 AM	hr	104.0
VIT-008303	Mon Nov 02, 2026 11:45 AM	map	66.0
VIT-008304	Mon Nov 02, 2026 11:45 AM	gcs	15.0
VIT-008277	Mon Nov 02, 2026 07:45 PM	spo2	96.0	room air
VIT-008278	Mon Nov 02, 2026 07:45 PM	rr	19.0
VIT-008305	Mon Nov 02, 2026 07:45 PM	temp_c	36.6
VIT-008306	Mon Nov 02, 2026 07:45 PM	hr	68.0
VIT-008307	Mon Nov 02, 2026 07:45 PM	map	88.0
VIT-008308	Mon Nov 02, 2026 07:45 PM	gcs	15.0
VIT-008279	Tue Nov 03, 2026 03:45 AM	spo2	96.0	room air
VIT-008280	Tue Nov 03, 2026 03:45 AM	rr	21.0
VIT-008309	Tue Nov 03, 2026 03:45 AM	temp_c	36.9
VIT-008310	Tue Nov 03, 2026 03:45 AM	hr	87.0
VIT-008311	Tue Nov 03, 2026 03:45 AM	map	78.0
VIT-008312	Tue Nov 03, 2026 03:45 AM	gcs	15.0

Medications, orders, echo, history (11)

MED-000321 10-31 20:25 piperacillin-tazobactam per protocol IV
MED-000322 11-01 05:00 cefepime per protocol IV
MED-000323 11-02 05:00 ceftriaxone per protocol IV
MED-000324 10-31 08:00 furosemide 40 mg IV
MED-000325 10-31 20:00 furosemide 40 mg IV
MED-000326 11-01 08:00 furosemide 40 mg IV
MED-000327 11-01 20:00 furosemide 40 mg IV
MED-000328 11-02 08:00 furosemide 40 mg IV
MED-000329 11-02 20:00 furosemide 40 mg IV
ORD-000076 10-31 19:55 blood_culture: blood cultures x2
ECH-000039 2026-11-02 echo LVEF 29.0%

Notes

History and physical · DOC-000290 · Dr. Noor Halvorsen (resident) · Sat Oct 31, 2026 10:25 PM

Cited facts from this note (1)

infection_source: urinary tract infection · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… ice: Hospital Medicine Attending: Dr. Wes Merriweather History of present illness: 76-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: hypertension. Review of systems otherwise negative. Exam: Lungs: scattered crackles at the bases, no distress. Assessment …

Source document DOC-000290: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Camila Upfield   MRN: MRN78105176   Admitted: 2026-10-31 19:25
Service: Hospital Medicine   Attending: Dr. Wes Merriweather

History of present illness: 76-year-old man admitted with sepsis. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: hypertension.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Urinary tract infection: antibiotics.

Wound care note · DOC-000289 · Elena Jessup, RN, CWOCN (wound_nurse) · Mon Nov 02, 2026 03:25 AM

Cited facts from this note (2)

wound_site: sacral · cited p. 1, line 3 · confidence 0.85

Show source for wound_site

Wound/ostomy nurse follow-up Sacral pressure injury, Stage II. Partial-thickness skin loss with exposed dermis. Measures 5.3 x 3.3 x 0.6 cm. Turning schedule reinforced with staff; low-air-loss surface ordered.
wound_stage: Not found · quoted span not found in source · value withheld

Source document DOC-000289: Wound care note (synthetic)

Wound/ostomy nurse follow-up

Sacral pressure injury, Stage II. Partial-thickness skin loss with exposed dermis. Measures 5.3 x 3.3 x 0.6 cm.
Turning schedule reinforced with staff; low-air-loss surface ordered.

Progress note · DOC-000291 · Dr. Noor Halvorsen (resident) · Mon Nov 02, 2026 09:25 PM

Source document DOC-000291: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Camila Upfield   MRN: MRN78105176   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Sepsis: continue current management.
2. HFrEF: diuresis and daily weights; monitor electrolytes.
3. Acute hypoxic respiratory failure: supplemental oxygen, wean as tolerated.
4. Stage 4 sacral pressure ulcer: wound care following, offloading.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000292 · Dr. Wes Merriweather (attending) · Tue Nov 03, 2026 10:16 AM

Source document DOC-000292: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Camila Upfield   MRN: MRN78105176
Admitted 2026-10-31; discharged 2026-11-03.

Discharge diagnoses:
- sepsis
- urinary tract infection
- HFrEF
- acute hypoxic respiratory failure
- stage 4 sacral pressure ulcer
- hypertension

Disposition: home with follow-up.