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-00112: Jalen Hartwell

73F · MRN95014604 · Hospital Medicine · admitted Mon Oct 26, 2026 06:42 PM · discharged Sun Nov 01, 2026 10:50 AM · attending Dr. Gideon Zeller · resident Dr. Greta Kowalczyk · 154 cm, 46.5 kg

Documented diagnoses (current)

Principal: “urinary tract infection” · N39.0 Urinary tract infection, site not specified

Illustrative grouping now: MS-DRG 690 Kidney and urinary tract infections without MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 690.

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=1.055, 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=1.055, t.ratio_s3=3.0, creat_peak=0.77, 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=1.055, 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=F, hgb_nadir=12.38, 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=12.38, 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=338, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=89.7, egfr_late=86.8	89.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=89.7, t.g2=60, egfr_late=86.8	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=89.7, 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=89.7, egfr_late=86.8, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=89.7, 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=138.0, 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=138.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=138.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=138.0, 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=73, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=19.6, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=19.6, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=19.6, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=19.6, 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=37.2, t.t_hi=38, temp_min_48h=36.8, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=90.0, 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=10.82, t.wbc_hi=12, wbc_min_48h=5.68, 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=233.0	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=0.71	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=0.77	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=0.73	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 (38)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-003797	Sun Oct 12, 2025 09:15 AM	creatinine	0.71 mg/dL
LAB-003798	Tue Sep 15, 2026 10:05 AM	creatinine	0.73 mg/dL
LAB-003799	Mon Oct 26, 2026 07:42 PM	creatinine	0.77 mg/dL
LAB-003806	Mon Oct 26, 2026 07:42 PM	sodium	141.0 mmol/L
LAB-003813	Mon Oct 26, 2026 07:42 PM	hemoglobin	12.85 g/dL
LAB-003820	Mon Oct 26, 2026 07:42 PM	wbc	10.82 x10^3/uL
LAB-003821	Mon Oct 26, 2026 07:42 PM	platelets	300.0 x10^3/uL
LAB-003834	Mon Oct 26, 2026 07:42 PM	bilirubin	0.71 mg/dL
LAB-003800	Tue Oct 27, 2026 05:00 AM	creatinine	0.73 mg/dL
LAB-003807	Tue Oct 27, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-003814	Tue Oct 27, 2026 05:00 AM	hemoglobin	12.82 g/dL
LAB-003822	Tue Oct 27, 2026 05:00 AM	wbc	6.02 x10^3/uL
LAB-003823	Tue Oct 27, 2026 05:00 AM	platelets	233.0 x10^3/uL
LAB-003801	Wed Oct 28, 2026 05:00 AM	creatinine	0.73 mg/dL
LAB-003808	Wed Oct 28, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-003815	Wed Oct 28, 2026 05:00 AM	hemoglobin	12.58 g/dL
LAB-003824	Wed Oct 28, 2026 05:00 AM	wbc	5.68 x10^3/uL
LAB-003825	Wed Oct 28, 2026 05:00 AM	platelets	279.0 x10^3/uL
LAB-003802	Thu Oct 29, 2026 05:00 AM	creatinine	0.76 mg/dL
LAB-003809	Thu Oct 29, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-003816	Thu Oct 29, 2026 05:00 AM	hemoglobin	12.46 g/dL
LAB-003826	Thu Oct 29, 2026 05:00 AM	wbc	10.66 x10^3/uL
LAB-003827	Thu Oct 29, 2026 05:00 AM	platelets	175.0 x10^3/uL
LAB-003803	Fri Oct 30, 2026 05:00 AM	creatinine	0.74 mg/dL
LAB-003810	Fri Oct 30, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-003817	Fri Oct 30, 2026 05:00 AM	hemoglobin	12.38 g/dL
LAB-003828	Fri Oct 30, 2026 05:00 AM	wbc	8.96 x10^3/uL
LAB-003829	Fri Oct 30, 2026 05:00 AM	platelets	250.0 x10^3/uL
LAB-003804	Sat Oct 31, 2026 05:00 AM	creatinine	0.76 mg/dL
LAB-003811	Sat Oct 31, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-003818	Sat Oct 31, 2026 05:00 AM	hemoglobin	12.51 g/dL
LAB-003830	Sat Oct 31, 2026 05:00 AM	wbc	7.32 x10^3/uL
LAB-003831	Sat Oct 31, 2026 05:00 AM	platelets	184.0 x10^3/uL
LAB-003805	Sun Nov 01, 2026 05:00 AM	creatinine	0.73 mg/dL
LAB-003812	Sun Nov 01, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-003819	Sun Nov 01, 2026 05:00 AM	hemoglobin	12.51 g/dL
LAB-003832	Sun Nov 01, 2026 05:00 AM	wbc	9.08 x10^3/uL
LAB-003833	Sun Nov 01, 2026 05:00 AM	platelets	179.0 x10^3/uL

Vitals (102)

Vitals
Row	When	Kind	Value	Detail
VIT-010912	Mon Oct 26, 2026 07:02 PM	spo2	99.0	room air
VIT-010913	Mon Oct 26, 2026 07:02 PM	rr	18.0
VIT-010946	Mon Oct 26, 2026 07:02 PM	temp_c	36.9
VIT-010947	Mon Oct 26, 2026 07:02 PM	hr	74.0
VIT-010948	Mon Oct 26, 2026 07:02 PM	map	81.0
VIT-010949	Mon Oct 26, 2026 07:02 PM	gcs	15.0
VIT-010914	Tue Oct 27, 2026 03:02 AM	spo2	99.0	room air
VIT-010915	Tue Oct 27, 2026 03:02 AM	rr	15.0
VIT-010950	Tue Oct 27, 2026 03:02 AM	temp_c	36.9
VIT-010951	Tue Oct 27, 2026 03:02 AM	hr	71.0
VIT-010952	Tue Oct 27, 2026 03:02 AM	map	81.0
VIT-010953	Tue Oct 27, 2026 03:02 AM	gcs	15.0
VIT-010916	Tue Oct 27, 2026 11:02 AM	spo2	98.0	room air
VIT-010917	Tue Oct 27, 2026 11:02 AM	rr	14.0
VIT-010954	Tue Oct 27, 2026 11:02 AM	temp_c	37.2
VIT-010955	Tue Oct 27, 2026 11:02 AM	hr	68.0
VIT-010956	Tue Oct 27, 2026 11:02 AM	map	92.0
VIT-010957	Tue Oct 27, 2026 11:02 AM	gcs	15.0
VIT-010918	Tue Oct 27, 2026 07:02 PM	spo2	99.0	room air
VIT-010919	Tue Oct 27, 2026 07:02 PM	rr	19.0
VIT-010958	Tue Oct 27, 2026 07:02 PM	temp_c	36.8
VIT-010959	Tue Oct 27, 2026 07:02 PM	hr	78.0
VIT-010960	Tue Oct 27, 2026 07:02 PM	map	90.0
VIT-010961	Tue Oct 27, 2026 07:02 PM	gcs	15.0
VIT-010920	Wed Oct 28, 2026 03:02 AM	spo2	97.0	room air
VIT-010921	Wed Oct 28, 2026 03:02 AM	rr	16.0
VIT-010962	Wed Oct 28, 2026 03:02 AM	temp_c	36.9
VIT-010963	Wed Oct 28, 2026 03:02 AM	hr	87.0
VIT-010964	Wed Oct 28, 2026 03:02 AM	map	79.0
VIT-010965	Wed Oct 28, 2026 03:02 AM	gcs	15.0
VIT-010922	Wed Oct 28, 2026 11:02 AM	spo2	95.0	room air
VIT-010923	Wed Oct 28, 2026 11:02 AM	rr	18.0
VIT-010966	Wed Oct 28, 2026 11:02 AM	temp_c	37.0
VIT-010967	Wed Oct 28, 2026 11:02 AM	hr	90.0
VIT-010968	Wed Oct 28, 2026 11:02 AM	map	79.0
VIT-010969	Wed Oct 28, 2026 11:02 AM	gcs	15.0
VIT-010924	Wed Oct 28, 2026 07:02 PM	spo2	96.0	room air
VIT-010925	Wed Oct 28, 2026 07:02 PM	rr	16.0
VIT-010970	Wed Oct 28, 2026 07:02 PM	temp_c	36.7
VIT-010971	Wed Oct 28, 2026 07:02 PM	hr	81.0
VIT-010972	Wed Oct 28, 2026 07:02 PM	map	91.0
VIT-010973	Wed Oct 28, 2026 07:02 PM	gcs	15.0
VIT-010926	Thu Oct 29, 2026 03:02 AM	spo2	94.0	room air
VIT-010927	Thu Oct 29, 2026 03:02 AM	rr	16.0
VIT-010974	Thu Oct 29, 2026 03:02 AM	temp_c	36.9
VIT-010975	Thu Oct 29, 2026 03:02 AM	hr	89.0
VIT-010976	Thu Oct 29, 2026 03:02 AM	map	89.0
VIT-010977	Thu Oct 29, 2026 03:02 AM	gcs	15.0
VIT-010928	Thu Oct 29, 2026 11:02 AM	spo2	95.0	room air
VIT-010929	Thu Oct 29, 2026 11:02 AM	rr	14.0
VIT-010978	Thu Oct 29, 2026 11:02 AM	temp_c	37.3
VIT-010979	Thu Oct 29, 2026 11:02 AM	hr	92.0
VIT-010980	Thu Oct 29, 2026 11:02 AM	map	89.0
VIT-010981	Thu Oct 29, 2026 11:02 AM	gcs	15.0
VIT-010930	Thu Oct 29, 2026 07:02 PM	spo2	95.0	room air
VIT-010931	Thu Oct 29, 2026 07:02 PM	rr	15.0
VIT-010982	Thu Oct 29, 2026 07:02 PM	temp_c	36.9
VIT-010983	Thu Oct 29, 2026 07:02 PM	hr	84.0
VIT-010984	Thu Oct 29, 2026 07:02 PM	map	78.0
VIT-010985	Thu Oct 29, 2026 07:02 PM	gcs	15.0
VIT-010932	Fri Oct 30, 2026 03:02 AM	spo2	97.0	room air
VIT-010933	Fri Oct 30, 2026 03:02 AM	rr	15.0
VIT-010986	Fri Oct 30, 2026 03:02 AM	temp_c	37.4
VIT-010987	Fri Oct 30, 2026 03:02 AM	hr	74.0
VIT-010988	Fri Oct 30, 2026 03:02 AM	map	87.0
VIT-010989	Fri Oct 30, 2026 03:02 AM	gcs	15.0
VIT-010934	Fri Oct 30, 2026 11:02 AM	spo2	97.0	room air
VIT-010935	Fri Oct 30, 2026 11:02 AM	rr	19.0
VIT-010990	Fri Oct 30, 2026 11:02 AM	temp_c	37.6
VIT-010991	Fri Oct 30, 2026 11:02 AM	hr	84.0
VIT-010992	Fri Oct 30, 2026 11:02 AM	map	79.0
VIT-010993	Fri Oct 30, 2026 11:02 AM	gcs	15.0
VIT-010936	Fri Oct 30, 2026 07:02 PM	spo2	98.0	room air
VIT-010937	Fri Oct 30, 2026 07:02 PM	rr	19.0
VIT-010994	Fri Oct 30, 2026 07:02 PM	temp_c	36.8
VIT-010995	Fri Oct 30, 2026 07:02 PM	hr	76.0
VIT-010996	Fri Oct 30, 2026 07:02 PM	map	89.0
VIT-010997	Fri Oct 30, 2026 07:02 PM	gcs	15.0
VIT-010938	Sat Oct 31, 2026 03:02 AM	spo2	94.0	room air
VIT-010939	Sat Oct 31, 2026 03:02 AM	rr	18.0
VIT-010998	Sat Oct 31, 2026 03:02 AM	temp_c	36.5
VIT-010999	Sat Oct 31, 2026 03:02 AM	hr	85.0
VIT-011000	Sat Oct 31, 2026 03:02 AM	map	83.0
VIT-011001	Sat Oct 31, 2026 03:02 AM	gcs	15.0
VIT-010940	Sat Oct 31, 2026 11:02 AM	spo2	94.0	room air
VIT-010941	Sat Oct 31, 2026 11:02 AM	rr	14.0
VIT-011002	Sat Oct 31, 2026 11:02 AM	temp_c	36.6
VIT-011003	Sat Oct 31, 2026 11:02 AM	hr	76.0
VIT-011004	Sat Oct 31, 2026 11:02 AM	map	74.0
VIT-011005	Sat Oct 31, 2026 11:02 AM	gcs	15.0
VIT-010942	Sat Oct 31, 2026 07:02 PM	spo2	94.0	room air
VIT-010943	Sat Oct 31, 2026 07:02 PM	rr	19.0
VIT-011006	Sat Oct 31, 2026 07:02 PM	temp_c	37.4
VIT-011007	Sat Oct 31, 2026 07:02 PM	hr	72.0
VIT-011008	Sat Oct 31, 2026 07:02 PM	map	84.0
VIT-011009	Sat Oct 31, 2026 07:02 PM	gcs	15.0
VIT-010944	Sun Nov 01, 2026 03:02 AM	spo2	98.0	room air
VIT-010945	Sun Nov 01, 2026 03:02 AM	rr	20.0
VIT-011010	Sun Nov 01, 2026 03:02 AM	temp_c	37.2
VIT-011011	Sun Nov 01, 2026 03:02 AM	hr	86.0
VIT-011012	Sun Nov 01, 2026 03:02 AM	map	92.0
VIT-011013	Sun Nov 01, 2026 03:02 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000439 10-26 19:42 ceftriaxone per protocol IV
MED-000440 10-27 05:00 piperacillin-tazobactam per protocol IV
MED-000441 10-28 05:00 ceftriaxone per protocol IV
ORD-000096 10-26 19:12 blood_culture: blood cultures x2

Notes

History and physical · DOC-000377 · Dr. Greta Kowalczyk (resident) · Mon Oct 26, 2026 09:42 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

… MRN95014604 Admitted: 2026-10-26 18:42 Service: Hospital Medicine Attending: Dr. Gideon Zeller History of present illness: 73-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime. Past medical history: none significant. Review of systems otherwise negative. Exam: …

Source document DOC-000377: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Jalen Hartwell   MRN: MRN95014604   Admitted: 2026-10-26 18:42
Service: Hospital Medicine   Attending: Dr. Gideon Zeller

History of present illness: 73-year-old woman admitted with urinary tract infection. Urinalysis with pyuria; treated for urinary tract infection with cefepime.
Past medical history: none significant.
Review of systems otherwise negative.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Urinary tract infection: antibiotics.

Progress note · DOC-000378 · Dr. Greta Kowalczyk (resident) · Wed Oct 28, 2026 09:42 PM

Source document DOC-000378: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Jalen Hartwell   MRN: MRN95014604   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Urinary tract infection: continue current management.

Resident: Dr. Greta Kowalczyk   Attending cosign: completed

Discharge summary · DOC-000379 · Dr. Gideon Zeller (attending) · Sun Nov 01, 2026 10:50 AM

Source document DOC-000379: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Jalen Hartwell   MRN: MRN95014604
Admitted 2026-10-26; discharged 2026-11-01.

Discharge diagnoses:
- urinary tract infection

Disposition: home with follow-up.