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-00180: Uma Bellweather

69M · MRN73957296 · Hospital Medicine · admitted Wed Nov 04, 2026 07:35 PM · discharged Tue Nov 10, 2026 01:59 PM · attending Dr. Rosalind Quillan · resident Dr. Priya Thorne · 165 cm, 61.7 kg

Documented diagnoses (current)

Principal: “sepsis” · A41.9 Sepsis, unspecified organism
“community-acquired pneumonia” · J18.9 Pneumonia, unspecified organism
“hypertension” · I10 Essential (primary) hypertension
“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=1.032, t.ratio_s1=1.5, creat_rise_48h=0.05, 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=1.032, t.ratio_s3=3.0, creat_peak=0.97, 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=1.032, 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=0.05, 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=14.22, 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=0.3, 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=0.3, t.drop_min=1.0, prbc_units=0	false
outcome: not_anaemic	`present(hgb_nadir) and not anaemic`	hgb_nadir=14.22, 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=351, t.chronic_days=90	true
derived: staging_egfr	`max(egfr_early, egfr_late)`	egfr_early=83.5, egfr_late=87.8	87.8
derived: both_below_60	`egfr_early < t.g2 and egfr_late < t.g2`	egfr_early=83.5, t.g2=60, egfr_late=87.8	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=87.8, 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=83.5, egfr_late=87.8, t.g2=60	false
outcome: g1_g2	`staging_egfr >= t.g2`	staging_egfr=87.8, 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=69, t.adult=20	false
outcome: class3	`bmi >= t.c3`	bmi=22.7, t.c3=40	false
outcome: class2	`bmi >= t.c2`	bmi=22.7, t.c2=35	false
outcome: class1	`bmi >= t.c1`	bmi=22.7, t.c1=30	false
outcome: not_met	`bmi < t.c1`	bmi=22.7, 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=39.2, t.t_hi=38, temp_min_48h=38.4, t.t_lo=36	true
derived: sirs_hr	`coalesce(hr_max_48h > t.hr, false)`	hr_max_48h=122.0, 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=18.17, t.wbc_hi=12, wbc_min_48h=14.96, 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=84.0	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=0.47	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=0.97	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=0.94	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=2.88, 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 (39)

Labs (pre-admission rows are outpatient values)
Row	When	Test	Value
LAB-006154	Fri Sep 26, 2025 09:15 AM	creatinine	0.98 mg/dL
LAB-006155	Sat Sep 12, 2026 10:05 AM	creatinine	0.94 mg/dL
LAB-006156	Wed Nov 04, 2026 08:35 PM	creatinine	0.92 mg/dL
LAB-006163	Wed Nov 04, 2026 08:35 PM	sodium	138.0 mmol/L
LAB-006170	Wed Nov 04, 2026 08:35 PM	hemoglobin	14.39 g/dL
LAB-006177	Wed Nov 04, 2026 08:35 PM	wbc	15.44 x10^3/uL
LAB-006178	Wed Nov 04, 2026 08:35 PM	platelets	88.0 x10^3/uL
LAB-006191	Wed Nov 04, 2026 08:35 PM	bilirubin	0.47 mg/dL
LAB-006192	Wed Nov 04, 2026 08:35 PM	lactate	2.88 mmol/L
LAB-006157	Thu Nov 05, 2026 05:00 AM	creatinine	0.93 mg/dL
LAB-006164	Thu Nov 05, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-006171	Thu Nov 05, 2026 05:00 AM	hemoglobin	14.25 g/dL
LAB-006179	Thu Nov 05, 2026 05:00 AM	wbc	18.17 x10^3/uL
LAB-006180	Thu Nov 05, 2026 05:00 AM	platelets	87.0 x10^3/uL
LAB-006158	Fri Nov 06, 2026 05:00 AM	creatinine	0.97 mg/dL
LAB-006165	Fri Nov 06, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-006172	Fri Nov 06, 2026 05:00 AM	hemoglobin	14.23 g/dL
LAB-006181	Fri Nov 06, 2026 05:00 AM	wbc	14.96 x10^3/uL
LAB-006182	Fri Nov 06, 2026 05:00 AM	platelets	84.0 x10^3/uL
LAB-006159	Sat Nov 07, 2026 05:00 AM	creatinine	0.94 mg/dL
LAB-006166	Sat Nov 07, 2026 05:00 AM	sodium	140.0 mmol/L
LAB-006173	Sat Nov 07, 2026 05:00 AM	hemoglobin	14.35 g/dL
LAB-006183	Sat Nov 07, 2026 05:00 AM	wbc	10.69 x10^3/uL
LAB-006184	Sat Nov 07, 2026 05:00 AM	platelets	293.0 x10^3/uL
LAB-006160	Sun Nov 08, 2026 05:00 AM	creatinine	0.94 mg/dL
LAB-006167	Sun Nov 08, 2026 05:00 AM	sodium	142.0 mmol/L
LAB-006174	Sun Nov 08, 2026 05:00 AM	hemoglobin	14.31 g/dL
LAB-006185	Sun Nov 08, 2026 05:00 AM	wbc	9.18 x10^3/uL
LAB-006186	Sun Nov 08, 2026 05:00 AM	platelets	307.0 x10^3/uL
LAB-006161	Mon Nov 09, 2026 05:00 AM	creatinine	0.95 mg/dL
LAB-006168	Mon Nov 09, 2026 05:00 AM	sodium	138.0 mmol/L
LAB-006175	Mon Nov 09, 2026 05:00 AM	hemoglobin	14.56 g/dL
LAB-006187	Mon Nov 09, 2026 05:00 AM	wbc	6.19 x10^3/uL
LAB-006188	Mon Nov 09, 2026 05:00 AM	platelets	292.0 x10^3/uL
LAB-006162	Tue Nov 10, 2026 05:00 AM	creatinine	0.94 mg/dL
LAB-006169	Tue Nov 10, 2026 05:00 AM	sodium	136.0 mmol/L
LAB-006176	Tue Nov 10, 2026 05:00 AM	hemoglobin	14.22 g/dL
LAB-006189	Tue Nov 10, 2026 05:00 AM	wbc	8.58 x10^3/uL
LAB-006190	Tue Nov 10, 2026 05:00 AM	platelets	277.0 x10^3/uL

Vitals (108)

Vitals
Row	When	Kind	Value	Detail
VIT-017697	Wed Nov 04, 2026 07:55 PM	spo2	94.0	room air
VIT-017698	Wed Nov 04, 2026 07:55 PM	rr	18.0
VIT-017733	Wed Nov 04, 2026 07:55 PM	temp_c	38.7
VIT-017734	Wed Nov 04, 2026 07:55 PM	hr	122.0
VIT-017735	Wed Nov 04, 2026 07:55 PM	map	64.0
VIT-017736	Wed Nov 04, 2026 07:55 PM	gcs	15.0
VIT-017699	Thu Nov 05, 2026 03:55 AM	spo2	94.0	room air
VIT-017700	Thu Nov 05, 2026 03:55 AM	rr	14.0
VIT-017737	Thu Nov 05, 2026 03:55 AM	temp_c	38.5
VIT-017738	Thu Nov 05, 2026 03:55 AM	hr	111.0
VIT-017739	Thu Nov 05, 2026 03:55 AM	map	66.0
VIT-017740	Thu Nov 05, 2026 03:55 AM	gcs	15.0
VIT-017701	Thu Nov 05, 2026 11:55 AM	spo2	96.0	room air
VIT-017702	Thu Nov 05, 2026 11:55 AM	rr	18.0
VIT-017741	Thu Nov 05, 2026 11:55 AM	temp_c	38.4
VIT-017742	Thu Nov 05, 2026 11:55 AM	hr	121.0
VIT-017743	Thu Nov 05, 2026 11:55 AM	map	64.0
VIT-017744	Thu Nov 05, 2026 11:55 AM	gcs	15.0
VIT-017703	Thu Nov 05, 2026 07:55 PM	spo2	98.0	room air
VIT-017704	Thu Nov 05, 2026 07:55 PM	rr	14.0
VIT-017745	Thu Nov 05, 2026 07:55 PM	temp_c	39.2
VIT-017746	Thu Nov 05, 2026 07:55 PM	hr	119.0
VIT-017747	Thu Nov 05, 2026 07:55 PM	map	65.0
VIT-017748	Thu Nov 05, 2026 07:55 PM	gcs	15.0
VIT-017705	Fri Nov 06, 2026 03:55 AM	spo2	97.0	room air
VIT-017706	Fri Nov 06, 2026 03:55 AM	rr	20.0
VIT-017749	Fri Nov 06, 2026 03:55 AM	temp_c	39.1
VIT-017750	Fri Nov 06, 2026 03:55 AM	hr	113.0
VIT-017751	Fri Nov 06, 2026 03:55 AM	map	68.0
VIT-017752	Fri Nov 06, 2026 03:55 AM	gcs	15.0
VIT-017707	Fri Nov 06, 2026 11:55 AM	spo2	96.0	room air
VIT-017708	Fri Nov 06, 2026 11:55 AM	rr	14.0
VIT-017753	Fri Nov 06, 2026 11:55 AM	temp_c	38.6
VIT-017754	Fri Nov 06, 2026 11:55 AM	hr	121.0
VIT-017755	Fri Nov 06, 2026 11:55 AM	map	65.0
VIT-017756	Fri Nov 06, 2026 11:55 AM	gcs	15.0
VIT-017709	Fri Nov 06, 2026 07:55 PM	spo2	98.0	room air
VIT-017710	Fri Nov 06, 2026 07:55 PM	rr	14.0
VIT-017757	Fri Nov 06, 2026 07:55 PM	temp_c	36.9
VIT-017758	Fri Nov 06, 2026 07:55 PM	hr	69.0
VIT-017759	Fri Nov 06, 2026 07:55 PM	map	89.0
VIT-017760	Fri Nov 06, 2026 07:55 PM	gcs	15.0
VIT-017711	Sat Nov 07, 2026 03:55 AM	spo2	97.0	room air
VIT-017712	Sat Nov 07, 2026 03:55 AM	rr	17.0
VIT-017761	Sat Nov 07, 2026 03:55 AM	temp_c	36.6
VIT-017762	Sat Nov 07, 2026 03:55 AM	hr	81.0
VIT-017763	Sat Nov 07, 2026 03:55 AM	map	84.0
VIT-017764	Sat Nov 07, 2026 03:55 AM	gcs	15.0
VIT-017713	Sat Nov 07, 2026 11:55 AM	spo2	99.0	room air
VIT-017714	Sat Nov 07, 2026 11:55 AM	rr	14.0
VIT-017765	Sat Nov 07, 2026 11:55 AM	temp_c	36.9
VIT-017766	Sat Nov 07, 2026 11:55 AM	hr	75.0
VIT-017767	Sat Nov 07, 2026 11:55 AM	map	89.0
VIT-017768	Sat Nov 07, 2026 11:55 AM	gcs	15.0
VIT-017715	Sat Nov 07, 2026 07:55 PM	spo2	98.0	room air
VIT-017716	Sat Nov 07, 2026 07:55 PM	rr	15.0
VIT-017769	Sat Nov 07, 2026 07:55 PM	temp_c	37.3
VIT-017770	Sat Nov 07, 2026 07:55 PM	hr	88.0
VIT-017771	Sat Nov 07, 2026 07:55 PM	map	88.0
VIT-017772	Sat Nov 07, 2026 07:55 PM	gcs	15.0
VIT-017717	Sun Nov 08, 2026 03:55 AM	spo2	98.0	room air
VIT-017718	Sun Nov 08, 2026 03:55 AM	rr	15.0
VIT-017773	Sun Nov 08, 2026 03:55 AM	temp_c	36.7
VIT-017774	Sun Nov 08, 2026 03:55 AM	hr	77.0
VIT-017775	Sun Nov 08, 2026 03:55 AM	map	77.0
VIT-017776	Sun Nov 08, 2026 03:55 AM	gcs	15.0
VIT-017719	Sun Nov 08, 2026 11:55 AM	spo2	98.0	room air
VIT-017720	Sun Nov 08, 2026 11:55 AM	rr	16.0
VIT-017777	Sun Nov 08, 2026 11:55 AM	temp_c	37.0
VIT-017778	Sun Nov 08, 2026 11:55 AM	hr	81.0
VIT-017779	Sun Nov 08, 2026 11:55 AM	map	75.0
VIT-017780	Sun Nov 08, 2026 11:55 AM	gcs	15.0
VIT-017721	Sun Nov 08, 2026 07:55 PM	spo2	95.0	room air
VIT-017722	Sun Nov 08, 2026 07:55 PM	rr	16.0
VIT-017781	Sun Nov 08, 2026 07:55 PM	temp_c	36.8
VIT-017782	Sun Nov 08, 2026 07:55 PM	hr	71.0
VIT-017783	Sun Nov 08, 2026 07:55 PM	map	75.0
VIT-017784	Sun Nov 08, 2026 07:55 PM	gcs	15.0
VIT-017723	Mon Nov 09, 2026 03:55 AM	spo2	96.0	room air
VIT-017724	Mon Nov 09, 2026 03:55 AM	rr	14.0
VIT-017785	Mon Nov 09, 2026 03:55 AM	temp_c	37.5
VIT-017786	Mon Nov 09, 2026 03:55 AM	hr	76.0
VIT-017787	Mon Nov 09, 2026 03:55 AM	map	85.0
VIT-017788	Mon Nov 09, 2026 03:55 AM	gcs	15.0
VIT-017725	Mon Nov 09, 2026 11:55 AM	spo2	98.0	room air
VIT-017726	Mon Nov 09, 2026 11:55 AM	rr	20.0
VIT-017789	Mon Nov 09, 2026 11:55 AM	temp_c	36.5
VIT-017790	Mon Nov 09, 2026 11:55 AM	hr	78.0
VIT-017791	Mon Nov 09, 2026 11:55 AM	map	75.0
VIT-017792	Mon Nov 09, 2026 11:55 AM	gcs	15.0
VIT-017727	Mon Nov 09, 2026 07:55 PM	spo2	99.0	room air
VIT-017728	Mon Nov 09, 2026 07:55 PM	rr	18.0
VIT-017793	Mon Nov 09, 2026 07:55 PM	temp_c	37.1
VIT-017794	Mon Nov 09, 2026 07:55 PM	hr	71.0
VIT-017795	Mon Nov 09, 2026 07:55 PM	map	82.0
VIT-017796	Mon Nov 09, 2026 07:55 PM	gcs	15.0
VIT-017729	Tue Nov 10, 2026 03:55 AM	spo2	94.0	room air
VIT-017730	Tue Nov 10, 2026 03:55 AM	rr	17.0
VIT-017797	Tue Nov 10, 2026 03:55 AM	temp_c	37.3
VIT-017798	Tue Nov 10, 2026 03:55 AM	hr	81.0
VIT-017799	Tue Nov 10, 2026 03:55 AM	map	74.0
VIT-017800	Tue Nov 10, 2026 03:55 AM	gcs	15.0
VIT-017731	Tue Nov 10, 2026 11:55 AM	spo2	99.0	room air
VIT-017732	Tue Nov 10, 2026 11:55 AM	rr	17.0
VIT-017801	Tue Nov 10, 2026 11:55 AM	temp_c	36.6
VIT-017802	Tue Nov 10, 2026 11:55 AM	hr	79.0
VIT-017803	Tue Nov 10, 2026 11:55 AM	map	88.0
VIT-017804	Tue Nov 10, 2026 11:55 AM	gcs	15.0

Medications, orders, echo, history (4)

MED-000711 11-04 20:35 ceftriaxone per protocol IV
MED-000712 11-05 05:00 piperacillin-tazobactam per protocol IV
MED-000713 11-06 05:00 ceftriaxone per protocol IV
ORD-000156 11-04 20:05 blood_culture: blood cultures x2

Notes

History and physical · DOC-000604 · Dr. Priya Thorne (resident) · Wed Nov 04, 2026 10:35 PM

Cited facts from this note (1)

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

Show source for infection_source

… 6-11-04 19:35 Service: Hospital Medicine Attending: Dr. Rosalind Quillan History of present illness: 69-year-old man admitted with sepsis. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started. Past medical history: hypertension, type 2 diabetes. Review of systems otherwise negative. Exam: Lungs: scattere …

Source document DOC-000604: History and physical (synthetic)

HISTORY AND PHYSICAL
Patient: Uma Bellweather   MRN: MRN73957296   Admitted: 2026-11-04 19:35
Service: Hospital Medicine   Attending: Dr. Rosalind Quillan

History of present illness: 69-year-old man admitted with sepsis. Chest x-ray shows right lower lobe pneumonia; blood cultures drawn and ceftriaxone started.
Past medical history: hypertension, 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.

Nutrition assessment · DOC-000603 · Vera Pemberton, RD (dietitian) · Thu Nov 05, 2026 11:35 PM

Cited facts from this note (5)

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

Show source for fat_loss

… MRN: MRN73957296 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: Uma Bellweather MRN: MRN73957296 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: Uma Bellweather MRN: MRN73957296 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-000603: Nutrition assessment (synthetic)

NUTRITION ASSESSMENT (Registered Dietitian)
Patient: Uma Bellweather   MRN: MRN73957296

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-000605 · Dr. Priya Thorne (resident) · Fri Nov 06, 2026 09:35 PM

Source document DOC-000605: Progress note (synthetic)

PROGRESS NOTE (Resident)
Patient: Uma Bellweather   MRN: MRN73957296   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. Priya Thorne   Attending cosign: completed

Discharge summary · DOC-000606 · Dr. Rosalind Quillan (attending) · Tue Nov 10, 2026 01:59 PM

Source document DOC-000606: Discharge summary (synthetic)

DISCHARGE SUMMARY
Patient: Uma Bellweather   MRN: MRN73957296
Admitted 2026-11-04; discharged 2026-11-10.

Discharge diagnoses:
- sepsis
- community-acquired pneumonia
- hypertension
- type 2 diabetes

Disposition: home with follow-up.