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-00113: Camila Sallow

78M · MRN58584417 · Cardiology · admitted Wed Nov 04, 2026 04:37 PM · discharged Tue Nov 10, 2026 12:56 PM · attending Dr. Kenji Stavros · resident Dr. Noor Halvorsen · 172 cm, 69.6 kg

Documented diagnoses (current)

Principal: “chronic systolic heart failure” · I50.22 Chronic systolic (congestive) heart failure

Illustrative grouping now: MS-DRG 293 Heart failure and shock without CC/MCC. If every open specificity/validation gap were answered as the criteria suggest: MS-DRG 293.

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=1.049, t.ratio_s1=1.5, creat_rise_48h=0.04, 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=1.049, t.ratio_s3=3.0, creat_peak=1.08, 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=1.049, 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=0.04, 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=14.58, 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=True, 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=14.58, 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=196, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=77.0, egfr_late=74.4	77.0
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=77.0, t.g2=60, egfr_late=74.4	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=77.0, 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=77.0, egfr_late=74.4, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=77.0, t.g2=60	true

Heart failure

Criteria met

No gap

Supported as documented (I50.22).

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=70.0, 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=31.0, 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=31.0, 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=0, hf_history=True	chronic
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=chronic	false
outcome: sys_acute	`hf_type == 'systolic' and acuity == 'acute'`	hf_type=systolic, acuity=chronic	false
outcome: sys_chronic	`hf_type == 'systolic' and acuity == 'chronic'`	hf_type=systolic, acuity=chronic	true

Hyponatraemia

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule hyponatremia v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: severity	`case(na_min < t.profound, 'profound', na_min < t.moderate, 'moderate', na_min < t.low, 'mild', 'none')`	na_min=136.0, t.profound=125, t.moderate=130, t.low=135	none
outcome: met	`na_min < t.low and na_low_count >= t.repeat and na_treated`	na_min=136.0, t.low=135, na_low_count=0, t.repeat=2, na_treated=False	false
outcome: untreated	`na_min < t.low`	na_min=136.0, t.low=135	false
outcome: not_met	`na_min >= t.low`	na_min=136.0, t.low=135	true

Malnutrition

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule malnutrition v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
derived: a_sev_intake	`intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days`	intake_pct=100.0, t.a_sev_intake_pct=50, intake_days=unknown, t.a_sev_intake_days=5	false
derived: a_mod_intake	`intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days`	intake_pct=100.0, t.a_mod_intake_pct=75, intake_days=unknown, t.a_mod_intake_days=7	false
derived: a_sev_wt	`(wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: a_mod_wt	`(wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_sev_intake	`intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=100.0, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	false
derived: c_mod_intake	`intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days`	intake_pct=100.0, t.c_intake_pct=75, intake_days=unknown, t.c_intake_days=30	false
derived: c_sev_wt	`(wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: c_mod_wt	`(wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20)`	wt_loss_days=unknown, wt_loss_pct=unknown	unknown
derived: n_assessed	`known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced)`	intake_pct=100.0, wt_loss_pct=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown	4
derived: n_severe	`case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null)`	nutr_context=acute, a_sev_intake=False, a_sev_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_sev_wt=unknown	0
derived: n_moderate	`case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null)`	nutr_context=acute, a_sev_intake=False, a_mod_intake=False, a_sev_wt=unknown, a_mod_wt=unknown, fat_loss=0, muscle_loss=0, fluid=0, grip_reduced=unknown, c_sev_intake=False, c_mod_intake=False, c_sev_wt=unknown, c_mod_wt=unknown	0
outcome: severe	`n_severe >= 2`	n_severe=0	false
outcome: moderate	`n_moderate >= 2`	n_moderate=0	false
outcome: one_characteristic	`n_moderate == 1`	n_moderate=0	false
outcome: not_met	`n_moderate == 0 and n_assessed >= 2`	n_moderate=0, n_assessed=4	true

Obesity

Criteria not met

No gap

Not documented and not supported.

Trace

Rule trace (rule obesity v2026.11-1; evaluated in order, first true outcome wins; "unknown" = missing input)
Step	Expression	Inputs and thresholds read	Result
outcome: not_adult	`age < t.adult`	age=78, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=23.5, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=23.5, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=23.5, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=23.5, t.c1=30	true

Pressure injury

Insufficient data

No gap

Insufficient data: the criteria could not be applied.

Trace

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

Acute respiratory failure

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=19.0, 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=36.5, t.t_lo=36	false
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=86.0, 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=17.0, 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=9.34, t.wbc_hi=12, wbc_min_48h=6.19, 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=218.0	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=0.9	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=74.0	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=1.07	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=1.03	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=False, sofa_delta=0, t.sofa_delta=2	false
derived: sepsis2	`infection_documented and sirs_count >= t.sirs_min`	infection_documented=False, 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=False	true

Structured data

Labs (39)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-003835	Wed Jan 07, 2026 09:15 AM	creatinine	1.0 mg/dL
LAB-003836	Thu Jul 23, 2026 10:05 AM	creatinine	1.03 mg/dL
LAB-003837	Wed Nov 04, 2026 05:37 PM	creatinine	1.07 mg/dL
LAB-003844	Wed Nov 04, 2026 05:37 PM	bnp	70.0 pg/mL
LAB-003845	Wed Nov 04, 2026 05:37 PM	sodium	140.0 mmol/L
LAB-003852	Wed Nov 04, 2026 05:37 PM	hemoglobin	14.83 g/dL
LAB-003859	Wed Nov 04, 2026 05:37 PM	wbc	8.92 x10^3/uL
LAB-003860	Wed Nov 04, 2026 05:37 PM	platelets	287.0 x10^3/uL
LAB-003873	Wed Nov 04, 2026 05:37 PM	bilirubin	0.9 mg/dL
LAB-003838	Thu Nov 05, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-003846	Thu Nov 05, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-003853	Thu Nov 05, 2026 05:00 AM	hemoglobin	14.99 g/dL
LAB-003861	Thu Nov 05, 2026 05:00 AM	wbc	9.34 x10^3/uL
LAB-003862	Thu Nov 05, 2026 05:00 AM	platelets	220.0 x10^3/uL
LAB-003839	Fri Nov 06, 2026 05:00 AM	creatinine	1.07 mg/dL
LAB-003847	Fri Nov 06, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-003854	Fri Nov 06, 2026 05:00 AM	hemoglobin	14.58 g/dL
LAB-003863	Fri Nov 06, 2026 05:00 AM	wbc	6.19 x10^3/uL
LAB-003864	Fri Nov 06, 2026 05:00 AM	platelets	218.0 x10^3/uL
LAB-003840	Sat Nov 07, 2026 05:00 AM	creatinine	1.06 mg/dL
LAB-003848	Sat Nov 07, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-003855	Sat Nov 07, 2026 05:00 AM	hemoglobin	14.69 g/dL
LAB-003865	Sat Nov 07, 2026 05:00 AM	wbc	7.23 x10^3/uL
LAB-003866	Sat Nov 07, 2026 05:00 AM	platelets	299.0 x10^3/uL
LAB-003841	Sun Nov 08, 2026 05:00 AM	creatinine	1.04 mg/dL
LAB-003849	Sun Nov 08, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-003856	Sun Nov 08, 2026 05:00 AM	hemoglobin	14.91 g/dL
LAB-003867	Sun Nov 08, 2026 05:00 AM	wbc	9.7 x10^3/uL
LAB-003868	Sun Nov 08, 2026 05:00 AM	platelets	176.0 x10^3/uL
LAB-003842	Mon Nov 09, 2026 05:00 AM	creatinine	1.08 mg/dL
LAB-003850	Mon Nov 09, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-003857	Mon Nov 09, 2026 05:00 AM	hemoglobin	14.91 g/dL
LAB-003869	Mon Nov 09, 2026 05:00 AM	wbc	6.93 x10^3/uL
LAB-003870	Mon Nov 09, 2026 05:00 AM	platelets	230.0 x10^3/uL
LAB-003843	Tue Nov 10, 2026 05:00 AM	creatinine	1.05 mg/dL
LAB-003851	Tue Nov 10, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-003858	Tue Nov 10, 2026 05:00 AM	hemoglobin	14.95 g/dL
LAB-003871	Tue Nov 10, 2026 05:00 AM	wbc	7.76 x10^3/uL
LAB-003872	Tue Nov 10, 2026 05:00 AM	platelets	182.0 x10^3/uL

Vitals (108)

Vitals
Row	When	Kind	Value	Detail
VIT-011014	Wed Nov 04, 2026 04:57 PM	spo2	95.0	room air
VIT-011015	Wed Nov 04, 2026 04:57 PM	rr	14.0
VIT-011050	Wed Nov 04, 2026 04:57 PM	temp_c	36.6
VIT-011051	Wed Nov 04, 2026 04:57 PM	hr	76.0
VIT-011052	Wed Nov 04, 2026 04:57 PM	map	74.0
VIT-011053	Wed Nov 04, 2026 04:57 PM	gcs	15.0
VIT-011016	Thu Nov 05, 2026 12:57 AM	spo2	97.0	room air
VIT-011017	Thu Nov 05, 2026 12:57 AM	rr	16.0
VIT-011054	Thu Nov 05, 2026 12:57 AM	temp_c	36.7
VIT-011055	Thu Nov 05, 2026 12:57 AM	hr	72.0
VIT-011056	Thu Nov 05, 2026 12:57 AM	map	78.0
VIT-011057	Thu Nov 05, 2026 12:57 AM	gcs	15.0
VIT-011018	Thu Nov 05, 2026 08:57 AM	spo2	99.0	room air
VIT-011019	Thu Nov 05, 2026 08:57 AM	rr	15.0
VIT-011058	Thu Nov 05, 2026 08:57 AM	temp_c	37.0
VIT-011059	Thu Nov 05, 2026 08:57 AM	hr	80.0
VIT-011060	Thu Nov 05, 2026 08:57 AM	map	88.0
VIT-011061	Thu Nov 05, 2026 08:57 AM	gcs	15.0
VIT-011020	Thu Nov 05, 2026 04:57 PM	spo2	99.0	room air
VIT-011021	Thu Nov 05, 2026 04:57 PM	rr	17.0
VIT-011062	Thu Nov 05, 2026 04:57 PM	temp_c	36.6
VIT-011063	Thu Nov 05, 2026 04:57 PM	hr	85.0
VIT-011064	Thu Nov 05, 2026 04:57 PM	map	81.0
VIT-011065	Thu Nov 05, 2026 04:57 PM	gcs	15.0
VIT-011022	Fri Nov 06, 2026 12:57 AM	spo2	96.0	room air
VIT-011023	Fri Nov 06, 2026 12:57 AM	rr	15.0
VIT-011066	Fri Nov 06, 2026 12:57 AM	temp_c	37.4
VIT-011067	Fri Nov 06, 2026 12:57 AM	hr	74.0
VIT-011068	Fri Nov 06, 2026 12:57 AM	map	87.0
VIT-011069	Fri Nov 06, 2026 12:57 AM	gcs	15.0
VIT-011024	Fri Nov 06, 2026 08:57 AM	spo2	97.0	room air
VIT-011025	Fri Nov 06, 2026 08:57 AM	rr	17.0
VIT-011070	Fri Nov 06, 2026 08:57 AM	temp_c	36.5
VIT-011071	Fri Nov 06, 2026 08:57 AM	hr	86.0
VIT-011072	Fri Nov 06, 2026 08:57 AM	map	81.0
VIT-011073	Fri Nov 06, 2026 08:57 AM	gcs	15.0
VIT-011026	Fri Nov 06, 2026 04:57 PM	spo2	97.0	room air
VIT-011027	Fri Nov 06, 2026 04:57 PM	rr	19.0
VIT-011074	Fri Nov 06, 2026 04:57 PM	temp_c	37.3
VIT-011075	Fri Nov 06, 2026 04:57 PM	hr	92.0
VIT-011076	Fri Nov 06, 2026 04:57 PM	map	82.0
VIT-011077	Fri Nov 06, 2026 04:57 PM	gcs	15.0
VIT-011028	Sat Nov 07, 2026 12:57 AM	spo2	98.0	room air
VIT-011029	Sat Nov 07, 2026 12:57 AM	rr	16.0
VIT-011078	Sat Nov 07, 2026 12:57 AM	temp_c	37.0
VIT-011079	Sat Nov 07, 2026 12:57 AM	hr	75.0
VIT-011080	Sat Nov 07, 2026 12:57 AM	map	80.0
VIT-011081	Sat Nov 07, 2026 12:57 AM	gcs	15.0
VIT-011030	Sat Nov 07, 2026 08:57 AM	spo2	98.0	room air
VIT-011031	Sat Nov 07, 2026 08:57 AM	rr	16.0
VIT-011082	Sat Nov 07, 2026 08:57 AM	temp_c	37.2
VIT-011083	Sat Nov 07, 2026 08:57 AM	hr	73.0
VIT-011084	Sat Nov 07, 2026 08:57 AM	map	92.0
VIT-011085	Sat Nov 07, 2026 08:57 AM	gcs	15.0
VIT-011032	Sat Nov 07, 2026 04:57 PM	spo2	95.0	room air
VIT-011033	Sat Nov 07, 2026 04:57 PM	rr	14.0
VIT-011086	Sat Nov 07, 2026 04:57 PM	temp_c	37.1
VIT-011087	Sat Nov 07, 2026 04:57 PM	hr	69.0
VIT-011088	Sat Nov 07, 2026 04:57 PM	map	76.0
VIT-011089	Sat Nov 07, 2026 04:57 PM	gcs	15.0
VIT-011034	Sun Nov 08, 2026 12:57 AM	spo2	95.0	room air
VIT-011035	Sun Nov 08, 2026 12:57 AM	rr	17.0
VIT-011090	Sun Nov 08, 2026 12:57 AM	temp_c	36.9
VIT-011091	Sun Nov 08, 2026 12:57 AM	hr	71.0
VIT-011092	Sun Nov 08, 2026 12:57 AM	map	79.0
VIT-011093	Sun Nov 08, 2026 12:57 AM	gcs	15.0
VIT-011036	Sun Nov 08, 2026 08:57 AM	spo2	98.0	room air
VIT-011037	Sun Nov 08, 2026 08:57 AM	rr	18.0
VIT-011094	Sun Nov 08, 2026 08:57 AM	temp_c	37.3
VIT-011095	Sun Nov 08, 2026 08:57 AM	hr	72.0
VIT-011096	Sun Nov 08, 2026 08:57 AM	map	87.0
VIT-011097	Sun Nov 08, 2026 08:57 AM	gcs	15.0
VIT-011038	Sun Nov 08, 2026 04:57 PM	spo2	95.0	room air
VIT-011039	Sun Nov 08, 2026 04:57 PM	rr	17.0
VIT-011098	Sun Nov 08, 2026 04:57 PM	temp_c	37.4
VIT-011099	Sun Nov 08, 2026 04:57 PM	hr	91.0
VIT-011100	Sun Nov 08, 2026 04:57 PM	map	79.0
VIT-011101	Sun Nov 08, 2026 04:57 PM	gcs	15.0
VIT-011040	Mon Nov 09, 2026 12:57 AM	spo2	99.0	room air
VIT-011041	Mon Nov 09, 2026 12:57 AM	rr	16.0
VIT-011102	Mon Nov 09, 2026 12:57 AM	temp_c	36.7
VIT-011103	Mon Nov 09, 2026 12:57 AM	hr	88.0
VIT-011104	Mon Nov 09, 2026 12:57 AM	map	86.0
VIT-011105	Mon Nov 09, 2026 12:57 AM	gcs	15.0
VIT-011042	Mon Nov 09, 2026 08:57 AM	spo2	97.0	room air
VIT-011043	Mon Nov 09, 2026 08:57 AM	rr	19.0
VIT-011106	Mon Nov 09, 2026 08:57 AM	temp_c	36.8
VIT-011107	Mon Nov 09, 2026 08:57 AM	hr	78.0
VIT-011108	Mon Nov 09, 2026 08:57 AM	map	76.0
VIT-011109	Mon Nov 09, 2026 08:57 AM	gcs	15.0
VIT-011044	Mon Nov 09, 2026 04:57 PM	spo2	95.0	room air
VIT-011045	Mon Nov 09, 2026 04:57 PM	rr	18.0
VIT-011110	Mon Nov 09, 2026 04:57 PM	temp_c	36.8
VIT-011111	Mon Nov 09, 2026 04:57 PM	hr	86.0
VIT-011112	Mon Nov 09, 2026 04:57 PM	map	78.0
VIT-011113	Mon Nov 09, 2026 04:57 PM	gcs	15.0
VIT-011046	Tue Nov 10, 2026 12:57 AM	spo2	94.0	room air
VIT-011047	Tue Nov 10, 2026 12:57 AM	rr	19.0
VIT-011114	Tue Nov 10, 2026 12:57 AM	temp_c	36.7
VIT-011115	Tue Nov 10, 2026 12:57 AM	hr	78.0
VIT-011116	Tue Nov 10, 2026 12:57 AM	map	90.0
VIT-011117	Tue Nov 10, 2026 12:57 AM	gcs	15.0
VIT-011048	Tue Nov 10, 2026 08:57 AM	spo2	94.0	room air
VIT-011049	Tue Nov 10, 2026 08:57 AM	rr	18.0
VIT-011118	Tue Nov 10, 2026 08:57 AM	temp_c	37.1
VIT-011119	Tue Nov 10, 2026 08:57 AM	hr	78.0
VIT-011120	Tue Nov 10, 2026 08:57 AM	map	74.0
VIT-011121	Tue Nov 10, 2026 08:57 AM	gcs	15.0

Medications, orders, echo, history (5)

MED-000442 11-04 09:37 furosemide 40 mg PO
MED-000443 11-05 09:00 furosemide 40 mg PO
MED-000444 11-06 09:00 furosemide 40 mg PO
ECH-000054 2026-11-05 echo LVEF 31.0%
HX-000044 history: heart failure with reduced ejection fraction

Notes

History and physical · DOC-000381 · Dr. Noor Halvorsen (resident) · Wed Nov 04, 2026 07:37 PM

Cited facts from this note (1)

bleeding_source: bleeding · cited p. 1, line 7 · confidence 0.50

Show source for bleeding_source

… y of present illness: 78-year-old man admitted with chronic systolic heart failure. Past medical history: heart failure with reduced ejection fraction. Denies bleeding, chest pain or fever. Exam: Lungs: clear to auscultation bilaterally. Assessment and plan: 1. Chronic systolic heart failure: diuresis and daily weights; monit …

Source document DOC-000381: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Camila Sallow   MRN: MRN58584417   Admitted: 2026-11-04 16:37
Service: Cardiology   Attending: Dr. Kenji Stavros

History of present illness: 78-year-old man admitted with chronic systolic heart failure. 
Past medical history: heart failure with reduced ejection fraction.
Denies bleeding, chest pain or fever.
Exam: Lungs: clear to auscultation bilaterally.
Assessment and plan:
1. Chronic systolic heart failure: diuresis and daily weights; monitor electrolytes.

Nutrition assessment · DOC-000380 · Dario Larkspur, RD (dietitian) · Thu Nov 05, 2026 10:37 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN58584417 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: Camila Sallow MRN: MRN58584417 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: Camila Sallow MRN: MRN58584417 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-000380: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Camila Sallow   MRN: MRN58584417

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-000382 · Dr. Noor Halvorsen (resident) · Fri Nov 06, 2026 08:37 PM

Source document DOC-000382: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Camila Sallow   MRN: MRN58584417   Hospital day 3

Subjective: resting, tolerating diet.
Objective: vitals and labs reviewed in the flowsheet.
Assessment and plan:
1. Chronic systolic heart failure: continue current management.

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000383 · Dr. Kenji Stavros (attending) · Tue Nov 10, 2026 12:56 PM

Source document DOC-000383: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Camila Sallow   MRN: MRN58584417
Admitted 2026-11-04; discharged 2026-11-10.

Discharge diagnoses:
- chronic systolic heart failure

Disposition: home with follow-up.