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-00086: Teodora Ravensworth

79M · MRN27831885 · Hospital Medicine · admitted Mon Nov 09, 2026 04:03 PM · in hospital · attending Dr. Rosalind Quillan · 173 cm, 69.6 kg

Documented diagnoses (current)

Principal: “community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“hypertension” · I10 Essential (primary) hypertension
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

Illustrative grouping now: MS-DRG 195 Simple pneumonia and pleurisy without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 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=1.045, t.ratio_s1=1.5, creat_rise_48h=0.03, 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=1.045, t.ratio_s3=3.0, creat_peak=1.17, 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=1.045, 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=0.03, 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=14.7, 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=0.5, 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=0.5, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.7, 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=254, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=69.8, egfr_late=66.8	69.8
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=69.8, t.g2=60, egfr_late=66.8	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=69.8, 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=69.8, egfr_late=66.8, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=69.8, 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=79, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.3, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.3, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.3, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.3, 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=37.5, 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=85.0, 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=9.76, t.wbc_hi=12, wbc_min_48h=6.45, 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=236.0	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=0.41	0
derived: sofa_cardio	`coalesce(case(norepi_max_48h > 0.1, 4, norepi_max_48h > 0, 3, map_min_48h < 70, 1, 0), 0)`	norepi_max_48h=0.0, map_min_48h=79.0	0
derived: sofa_cns	`coalesce(case(gcs_min_48h < 6, 4, gcs_min_48h < 10, 3, gcs_min_48h < 13, 2, gcs_min_48h < 15, 1, 0), 0)`	gcs_min_48h=15.0	0
derived: sofa_renal	`coalesce(case(creat_max_48h >= 5, 4, creat_max_48h >= 3.5, 3, creat_max_48h >= 2, 2, creat_max_48h >= 1.2, 1, 0), 0)`	creat_max_48h=1.17	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=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 (28)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-002889	Sun Dec 14, 2025 09:15 AM	creatinine	1.08 mg/dL
LAB-002890	Wed Aug 26, 2026 10:05 AM	creatinine	1.12 mg/dL
LAB-002891	Mon Nov 09, 2026 05:03 PM	creatinine	1.17 mg/dL
LAB-002896	Mon Nov 09, 2026 05:03 PM	sodium	139.0 mmol/L
LAB-002901	Mon Nov 09, 2026 05:03 PM	hemoglobin	14.76 g/dL
LAB-002906	Mon Nov 09, 2026 05:03 PM	wbc	9.76 x10^3/uL
LAB-002907	Mon Nov 09, 2026 05:03 PM	platelets	257.0 x10^3/uL
LAB-002916	Mon Nov 09, 2026 05:03 PM	bilirubin	0.41 mg/dL
LAB-002892	Tue Nov 10, 2026 05:00 AM	creatinine	1.1 mg/dL
LAB-002897	Tue Nov 10, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-002902	Tue Nov 10, 2026 05:00 AM	hemoglobin	15.18 g/dL
LAB-002908	Tue Nov 10, 2026 05:00 AM	wbc	6.45 x10^3/uL
LAB-002909	Tue Nov 10, 2026 05:00 AM	platelets	236.0 x10^3/uL
LAB-002893	Wed Nov 11, 2026 05:00 AM	creatinine	1.12 mg/dL
LAB-002898	Wed Nov 11, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-002903	Wed Nov 11, 2026 05:00 AM	hemoglobin	14.89 g/dL
LAB-002910	Wed Nov 11, 2026 05:00 AM	wbc	7.78 x10^3/uL
LAB-002911	Wed Nov 11, 2026 05:00 AM	platelets	307.0 x10^3/uL
LAB-002894	Thu Nov 12, 2026 05:00 AM	creatinine	1.13 mg/dL
LAB-002899	Thu Nov 12, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-002904	Thu Nov 12, 2026 05:00 AM	hemoglobin	14.7 g/dL
LAB-002912	Thu Nov 12, 2026 05:00 AM	wbc	9.36 x10^3/uL
LAB-002913	Thu Nov 12, 2026 05:00 AM	platelets	192.0 x10^3/uL
LAB-002895	Fri Nov 13, 2026 05:00 AM	creatinine	1.12 mg/dL
LAB-002900	Fri Nov 13, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-002905	Fri Nov 13, 2026 05:00 AM	hemoglobin	15.07 g/dL
LAB-002914	Fri Nov 13, 2026 05:00 AM	wbc	6.96 x10^3/uL
LAB-002915	Fri Nov 13, 2026 05:00 AM	platelets	282.0 x10^3/uL

Vitals (78)

Vitals
Row	When	Kind	Value	Detail
VIT-008313	Mon Nov 09, 2026 04:23 PM	spo2	98.0	room air
VIT-008314	Mon Nov 09, 2026 04:23 PM	rr	17.0
VIT-008339	Mon Nov 09, 2026 04:23 PM	temp_c	36.8
VIT-008340	Mon Nov 09, 2026 04:23 PM	hr	85.0
VIT-008341	Mon Nov 09, 2026 04:23 PM	map	79.0
VIT-008342	Mon Nov 09, 2026 04:23 PM	gcs	15.0
VIT-008315	Tue Nov 10, 2026 12:23 AM	spo2	96.0	room air
VIT-008316	Tue Nov 10, 2026 12:23 AM	rr	19.0
VIT-008343	Tue Nov 10, 2026 12:23 AM	temp_c	37.3
VIT-008344	Tue Nov 10, 2026 12:23 AM	hr	76.0
VIT-008345	Tue Nov 10, 2026 12:23 AM	map	79.0
VIT-008346	Tue Nov 10, 2026 12:23 AM	gcs	15.0
VIT-008317	Tue Nov 10, 2026 08:23 AM	spo2	94.0	room air
VIT-008318	Tue Nov 10, 2026 08:23 AM	rr	18.0
VIT-008347	Tue Nov 10, 2026 08:23 AM	temp_c	36.7
VIT-008348	Tue Nov 10, 2026 08:23 AM	hr	72.0
VIT-008349	Tue Nov 10, 2026 08:23 AM	map	84.0
VIT-008350	Tue Nov 10, 2026 08:23 AM	gcs	15.0
VIT-008319	Tue Nov 10, 2026 04:23 PM	spo2	99.0	room air
VIT-008320	Tue Nov 10, 2026 04:23 PM	rr	17.0
VIT-008351	Tue Nov 10, 2026 04:23 PM	temp_c	36.6
VIT-008352	Tue Nov 10, 2026 04:23 PM	hr	82.0
VIT-008353	Tue Nov 10, 2026 04:23 PM	map	86.0
VIT-008354	Tue Nov 10, 2026 04:23 PM	gcs	15.0
VIT-008321	Wed Nov 11, 2026 12:23 AM	spo2	96.0	room air
VIT-008322	Wed Nov 11, 2026 12:23 AM	rr	20.0
VIT-008355	Wed Nov 11, 2026 12:23 AM	temp_c	36.8
VIT-008356	Wed Nov 11, 2026 12:23 AM	hr	79.0
VIT-008357	Wed Nov 11, 2026 12:23 AM	map	92.0
VIT-008358	Wed Nov 11, 2026 12:23 AM	gcs	15.0
VIT-008323	Wed Nov 11, 2026 08:23 AM	spo2	98.0	room air
VIT-008324	Wed Nov 11, 2026 08:23 AM	rr	19.0
VIT-008359	Wed Nov 11, 2026 08:23 AM	temp_c	37.5
VIT-008360	Wed Nov 11, 2026 08:23 AM	hr	76.0
VIT-008361	Wed Nov 11, 2026 08:23 AM	map	92.0
VIT-008362	Wed Nov 11, 2026 08:23 AM	gcs	15.0
VIT-008325	Wed Nov 11, 2026 04:23 PM	spo2	98.0	room air
VIT-008326	Wed Nov 11, 2026 04:23 PM	rr	20.0
VIT-008363	Wed Nov 11, 2026 04:23 PM	temp_c	37.4
VIT-008364	Wed Nov 11, 2026 04:23 PM	hr	68.0
VIT-008365	Wed Nov 11, 2026 04:23 PM	map	82.0
VIT-008366	Wed Nov 11, 2026 04:23 PM	gcs	15.0
VIT-008327	Thu Nov 12, 2026 12:23 AM	spo2	97.0	room air
VIT-008328	Thu Nov 12, 2026 12:23 AM	rr	14.0
VIT-008367	Thu Nov 12, 2026 12:23 AM	temp_c	37.0
VIT-008368	Thu Nov 12, 2026 12:23 AM	hr	80.0
VIT-008369	Thu Nov 12, 2026 12:23 AM	map	86.0
VIT-008370	Thu Nov 12, 2026 12:23 AM	gcs	15.0
VIT-008329	Thu Nov 12, 2026 08:23 AM	spo2	96.0	room air
VIT-008330	Thu Nov 12, 2026 08:23 AM	rr	17.0
VIT-008371	Thu Nov 12, 2026 08:23 AM	temp_c	36.9
VIT-008372	Thu Nov 12, 2026 08:23 AM	hr	87.0
VIT-008373	Thu Nov 12, 2026 08:23 AM	map	76.0
VIT-008374	Thu Nov 12, 2026 08:23 AM	gcs	15.0
VIT-008331	Thu Nov 12, 2026 04:23 PM	spo2	98.0	room air
VIT-008332	Thu Nov 12, 2026 04:23 PM	rr	15.0
VIT-008375	Thu Nov 12, 2026 04:23 PM	temp_c	37.4
VIT-008376	Thu Nov 12, 2026 04:23 PM	hr	76.0
VIT-008377	Thu Nov 12, 2026 04:23 PM	map	89.0
VIT-008378	Thu Nov 12, 2026 04:23 PM	gcs	15.0
VIT-008333	Fri Nov 13, 2026 12:23 AM	spo2	94.0	room air
VIT-008334	Fri Nov 13, 2026 12:23 AM	rr	14.0
VIT-008379	Fri Nov 13, 2026 12:23 AM	temp_c	37.3
VIT-008380	Fri Nov 13, 2026 12:23 AM	hr	75.0
VIT-008381	Fri Nov 13, 2026 12:23 AM	map	74.0
VIT-008382	Fri Nov 13, 2026 12:23 AM	gcs	15.0
VIT-008335	Fri Nov 13, 2026 08:23 AM	spo2	97.0	room air
VIT-008336	Fri Nov 13, 2026 08:23 AM	rr	19.0
VIT-008383	Fri Nov 13, 2026 08:23 AM	temp_c	37.0
VIT-008384	Fri Nov 13, 2026 08:23 AM	hr	74.0
VIT-008385	Fri Nov 13, 2026 08:23 AM	map	74.0
VIT-008386	Fri Nov 13, 2026 08:23 AM	gcs	15.0
VIT-008337	Fri Nov 13, 2026 04:23 PM	spo2	98.0	room air
VIT-008338	Fri Nov 13, 2026 04:23 PM	rr	17.0
VIT-008387	Fri Nov 13, 2026 04:23 PM	temp_c	36.5
VIT-008388	Fri Nov 13, 2026 04:23 PM	hr	82.0
VIT-008389	Fri Nov 13, 2026 04:23 PM	map	76.0
VIT-008390	Fri Nov 13, 2026 04:23 PM	gcs	15.0

Medications, orders, echo, history (4)

MED-000330 11-09 17:03 piperacillin-tazobactam per protocol IV
MED-000331 11-10 05:00 ceftriaxone per protocol IV
MED-000332 11-11 05:00 piperacillin-tazobactam per protocol IV
ORD-000077 11-09 16:33 blood_culture: blood cultures x2

Notes

History and physical · DOC-000294 · Dr. Rosalind Quillan (attending) · Mon Nov 09, 2026 07:03 PM

Cited facts from this note (1)

infection_source: left lower lobe pneumonia · cited p. 1, line 5 · confidence 0.85

Show source for infection_source

… Hospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 79-year-old man admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, hypertension, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: cl …

Source document DOC-000294: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Teodora Ravensworth   MRN: MRN27831885   Admitted: 2026-11-09 16:03
Service: Hospital Medicine   Attending: Dr. Rosalind Quillan

History of present illness: 79-year-old man admitted with community-acquired pneumonia. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD, hypertension, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Community-acquired pneumonia: antibiotics.

Nutrition assessment · DOC-000293 · Dario Larkspur, RD (dietitian) · Tue Nov 10, 2026 09:03 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN27831885 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: Teodora Ravensworth MRN: MRN27831885 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: Teodora Ravensworth MRN: MRN27831885 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-000293: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Teodora Ravensworth   MRN: MRN27831885

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-000295 · Dr. Rosalind Quillan (attending) · Fri Nov 13, 2026 11:55 AM

Source document DOC-000295: Progress note (synthetic)

PROGRESS NOTE (Attending)
Patient: Teodora Ravensworth   MRN: MRN27831885   Hospital day 4

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Community-acquired pneumonia: continue current management.

Attending: Dr. Rosalind Quillan