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-00163: Wes Larkspur

56M · MRN94057495 · Hospital Medicine · admitted Thu Oct 29, 2026 11:54 AM · discharged Mon Nov 02, 2026 11:26 AM · attending Dr. Kenji Stavros · resident Dr. Noor Halvorsen · 181 cm, 72.7 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“GERD” · K21.9 Gastro-esophageal reflux disease without esophagitis
“hyperlipidemia” · E78.5 Hyperlipidemia, unspecified
“type 2 diabetes” · E11.9 Type 2 diabetes mellitus without complications

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=1.028, 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=1.028, t.ratio_s3=3.0, creat_peak=1.12, 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=1.028, 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=13.86, 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=0.1, 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=0.1, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=13.86, 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=264, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=79.7, egfr_late=79.7	79.7
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=79.7, t.g2=60, egfr_late=79.7	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=79.7, 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=79.7, egfr_late=79.7, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=79.7, 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=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

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=56, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=22.2, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=22.2, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=22.2, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=22.2, 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 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=38.5, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=115.0, 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=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=18.88, t.wbc_hi=12, wbc_min_48h=16.86, 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=False, sirs_wbc=True	3
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=87.0	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=0.83	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=64.0	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=1.11	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=1.09	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=3, 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=2.9, 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 (29)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-005563	Thu Nov 13, 2025 09:15 AM	creatinine	1.09 mg/dL
LAB-005564	Wed Aug 05, 2026 10:05 AM	creatinine	1.09 mg/dL
LAB-005565	Thu Oct 29, 2026 12:54 PM	creatinine	1.11 mg/dL
LAB-005570	Thu Oct 29, 2026 12:54 PM	sodium	139.0 mmol/L
LAB-005575	Thu Oct 29, 2026 12:54 PM	hemoglobin	13.88 g/dL
LAB-005580	Thu Oct 29, 2026 12:54 PM	wbc	18.88 x10^3/uL
LAB-005581	Thu Oct 29, 2026 12:54 PM	platelets	89.0 x10^3/uL
LAB-005590	Thu Oct 29, 2026 12:54 PM	bilirubin	0.83 mg/dL
LAB-005591	Thu Oct 29, 2026 12:54 PM	lactate	2.9 mmol/L
LAB-005566	Fri Oct 30, 2026 05:00 AM	creatinine	1.09 mg/dL
LAB-005571	Fri Oct 30, 2026 05:00 AM	sodium	139.0 mmol/L
LAB-005576	Fri Oct 30, 2026 05:00 AM	hemoglobin	13.93 g/dL
LAB-005582	Fri Oct 30, 2026 05:00 AM	wbc	16.86 x10^3/uL
LAB-005583	Fri Oct 30, 2026 05:00 AM	platelets	87.0 x10^3/uL
LAB-005567	Sat Oct 31, 2026 05:00 AM	creatinine	1.09 mg/dL
LAB-005572	Sat Oct 31, 2026 05:00 AM	sodium	137.0 mmol/L
LAB-005577	Sat Oct 31, 2026 05:00 AM	hemoglobin	13.86 g/dL
LAB-005584	Sat Oct 31, 2026 05:00 AM	wbc	18.76 x10^3/uL
LAB-005585	Sat Oct 31, 2026 05:00 AM	platelets	89.0 x10^3/uL
LAB-005568	Sun Nov 01, 2026 05:00 AM	creatinine	1.12 mg/dL
LAB-005573	Sun Nov 01, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-005578	Sun Nov 01, 2026 05:00 AM	hemoglobin	14.0 g/dL
LAB-005586	Sun Nov 01, 2026 05:00 AM	wbc	6.12 x10^3/uL
LAB-005587	Sun Nov 01, 2026 05:00 AM	platelets	304.0 x10^3/uL
LAB-005569	Mon Nov 02, 2026 05:00 AM	creatinine	1.08 mg/dL
LAB-005574	Mon Nov 02, 2026 05:00 AM	sodium	141.0 mmol/L
LAB-005579	Mon Nov 02, 2026 05:00 AM	hemoglobin	14.06 g/dL
LAB-005588	Mon Nov 02, 2026 05:00 AM	wbc	9.58 x10^3/uL
LAB-005589	Mon Nov 02, 2026 05:00 AM	platelets	170.0 x10^3/uL

Vitals (72)

Vitals
Row	When	Kind	Value	Detail
VIT-015995	Thu Oct 29, 2026 12:14 PM	spo2	94.0	room air
VIT-015996	Thu Oct 29, 2026 12:14 PM	rr	20.0
VIT-016019	Thu Oct 29, 2026 12:14 PM	temp_c	39.1
VIT-016020	Thu Oct 29, 2026 12:14 PM	hr	105.0
VIT-016021	Thu Oct 29, 2026 12:14 PM	map	64.0
VIT-016022	Thu Oct 29, 2026 12:14 PM	gcs	15.0
VIT-015997	Thu Oct 29, 2026 08:14 PM	spo2	99.0	room air
VIT-015998	Thu Oct 29, 2026 08:14 PM	rr	20.0
VIT-016023	Thu Oct 29, 2026 08:14 PM	temp_c	38.6
VIT-016024	Thu Oct 29, 2026 08:14 PM	hr	114.0
VIT-016025	Thu Oct 29, 2026 08:14 PM	map	65.0
VIT-016026	Thu Oct 29, 2026 08:14 PM	gcs	15.0
VIT-015999	Fri Oct 30, 2026 04:14 AM	spo2	99.0	room air
VIT-016000	Fri Oct 30, 2026 04:14 AM	rr	16.0
VIT-016027	Fri Oct 30, 2026 04:14 AM	temp_c	39.0
VIT-016028	Fri Oct 30, 2026 04:14 AM	hr	111.0
VIT-016029	Fri Oct 30, 2026 04:14 AM	map	67.0
VIT-016030	Fri Oct 30, 2026 04:14 AM	gcs	15.0
VIT-016001	Fri Oct 30, 2026 12:14 PM	spo2	97.0	room air
VIT-016002	Fri Oct 30, 2026 12:14 PM	rr	20.0
VIT-016031	Fri Oct 30, 2026 12:14 PM	temp_c	38.5
VIT-016032	Fri Oct 30, 2026 12:14 PM	hr	115.0
VIT-016033	Fri Oct 30, 2026 12:14 PM	map	66.0
VIT-016034	Fri Oct 30, 2026 12:14 PM	gcs	15.0
VIT-016003	Fri Oct 30, 2026 08:14 PM	spo2	96.0	room air
VIT-016004	Fri Oct 30, 2026 08:14 PM	rr	14.0
VIT-016035	Fri Oct 30, 2026 08:14 PM	temp_c	39.3
VIT-016036	Fri Oct 30, 2026 08:14 PM	hr	105.0
VIT-016037	Fri Oct 30, 2026 08:14 PM	map	67.0
VIT-016038	Fri Oct 30, 2026 08:14 PM	gcs	15.0
VIT-016005	Sat Oct 31, 2026 04:14 AM	spo2	95.0	room air
VIT-016006	Sat Oct 31, 2026 04:14 AM	rr	18.0
VIT-016039	Sat Oct 31, 2026 04:14 AM	temp_c	38.9
VIT-016040	Sat Oct 31, 2026 04:14 AM	hr	112.0
VIT-016041	Sat Oct 31, 2026 04:14 AM	map	67.0
VIT-016042	Sat Oct 31, 2026 04:14 AM	gcs	15.0
VIT-016007	Sat Oct 31, 2026 12:14 PM	spo2	99.0	room air
VIT-016008	Sat Oct 31, 2026 12:14 PM	rr	20.0
VIT-016043	Sat Oct 31, 2026 12:14 PM	temp_c	37.0
VIT-016044	Sat Oct 31, 2026 12:14 PM	hr	73.0
VIT-016045	Sat Oct 31, 2026 12:14 PM	map	84.0
VIT-016046	Sat Oct 31, 2026 12:14 PM	gcs	15.0
VIT-016009	Sat Oct 31, 2026 08:14 PM	spo2	97.0	room air
VIT-016010	Sat Oct 31, 2026 08:14 PM	rr	15.0
VIT-016047	Sat Oct 31, 2026 08:14 PM	temp_c	36.6
VIT-016048	Sat Oct 31, 2026 08:14 PM	hr	72.0
VIT-016049	Sat Oct 31, 2026 08:14 PM	map	78.0
VIT-016050	Sat Oct 31, 2026 08:14 PM	gcs	15.0
VIT-016011	Sun Nov 01, 2026 04:14 AM	spo2	98.0	room air
VIT-016012	Sun Nov 01, 2026 04:14 AM	rr	16.0
VIT-016051	Sun Nov 01, 2026 04:14 AM	temp_c	36.8
VIT-016052	Sun Nov 01, 2026 04:14 AM	hr	87.0
VIT-016053	Sun Nov 01, 2026 04:14 AM	map	89.0
VIT-016054	Sun Nov 01, 2026 04:14 AM	gcs	15.0
VIT-016013	Sun Nov 01, 2026 12:14 PM	spo2	99.0	room air
VIT-016014	Sun Nov 01, 2026 12:14 PM	rr	14.0
VIT-016055	Sun Nov 01, 2026 12:14 PM	temp_c	37.0
VIT-016056	Sun Nov 01, 2026 12:14 PM	hr	72.0
VIT-016057	Sun Nov 01, 2026 12:14 PM	map	80.0
VIT-016058	Sun Nov 01, 2026 12:14 PM	gcs	15.0
VIT-016015	Sun Nov 01, 2026 08:14 PM	spo2	96.0	room air
VIT-016016	Sun Nov 01, 2026 08:14 PM	rr	20.0
VIT-016059	Sun Nov 01, 2026 08:14 PM	temp_c	37.4
VIT-016060	Sun Nov 01, 2026 08:14 PM	hr	68.0
VIT-016061	Sun Nov 01, 2026 08:14 PM	map	79.0
VIT-016062	Sun Nov 01, 2026 08:14 PM	gcs	15.0
VIT-016017	Mon Nov 02, 2026 04:14 AM	spo2	97.0	room air
VIT-016018	Mon Nov 02, 2026 04:14 AM	rr	18.0
VIT-016063	Mon Nov 02, 2026 04:14 AM	temp_c	36.9
VIT-016064	Mon Nov 02, 2026 04:14 AM	hr	85.0
VIT-016065	Mon Nov 02, 2026 04:14 AM	map	90.0
VIT-016066	Mon Nov 02, 2026 04:14 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000660 10-29 12:54 cefepime per protocol IV
MED-000661 10-30 05:00 cefepime per protocol IV
MED-000662 10-31 05:00 piperacillin-tazobactam per protocol IV
ORD-000143 10-29 12:24 blood_culture: blood cultures x2

Notes

History and physical · DOC-000549 · Dr. Noor Halvorsen (resident) · Thu Oct 29, 2026 02:54 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

… 2026-10-29 11:54 Service: Hospital Medicine Attending: Dr. Kenji Stavros History of present illness: 56-year-old man admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: GERD, hyperlipidemia, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: …

Source document DOC-000549: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Wes Larkspur   MRN: MRN94057495   Admitted: 2026-10-29 11:54
Service: Hospital Medicine   Attending: Dr. Kenji Stavros

History of present illness: 56-year-old man admitted with sepsis. Chest x-ray shows left lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: GERD, hyperlipidemia, type 2 diabetes.
Review of systems otherwise negative.
Exam: Lungs: scattered crackles at the bases, no distress.
Assessment and plan:
1. Sepsis: antibiotics, fluids.
2. Community-acquired pneumonia: antibiotics.

Progress note · DOC-000550 · Dr. Noor Halvorsen (resident) · Sat Oct 31, 2026 12:54 PM

Source document DOC-000550: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Wes Larkspur   MRN: MRN94057495   Hospital day 3

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

Resident: Dr. Noor Halvorsen   Attending cosign: completed

Discharge summary · DOC-000551 · Dr. Kenji Stavros (attending) · Mon Nov 02, 2026 11:26 AM

Source document DOC-000551: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Wes Larkspur   MRN: MRN94057495
Admitted 2026-10-29; discharged 2026-11-02.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- GERD
- hyperlipidemia
- type 2 diabetes

Disposition: home with follow-up.