WAHS+ Interactive Per-Question Model & Citation Inspector (32 Cases)

### Clinical Problem List & Data Quality Findings
- **ACIP Immunization Schedule Anomaly: HPV Series (1 doses)** (CDC ACIP Schedule Anomaly): HPV immunization entries (2022-05-02 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [56] [74]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `17.03 g/dL` (`2020-12-28T21:08`) $\to$ range `12.18–17.03` $\to$ **latest `12.18 g/dL` (`2026-01-26T21:08`)** [decreasing / trending down] [18]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,069 tokens)
- **26 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 26 exact duplicate note attachments while preserving 26 unique clinical narratives. 
- **22 Raw Lab Measurements Consolidated Across 11 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. 
- **11 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 11 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [51] [62] [63] [71] [72] [57]
- **102 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 102 billing/administrative resources (Claim: 34, Device(clinic_equipment_retained): 9, ExplanationOfBenefit: 34, Medication: 3, Provenance: 1, SupplyDelivery: 21) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15.

• [18] Observation (83093df7-a1e4-b827-1b30-2e75a7463d5d): Finding — Hemoglobin [Mass/volume] in Blood: 12.18 g/dL (initial 17.03 on 2020-12-28 -> latest 12.18 on 2026-01-26; range 12.18 to 17.03 g/dL over n=2 measurements, first recorded 2020-12-28 through 2026-01-26, trend: down)
• [51] MedicationRequest (83093df7-a1e4-b827-0579-9a52cff34a9a): Medication: sodium fluoride 0.0272 MG/MG Oral Gel (status: completed, type: prescribed, reason: Gingivitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 1535362)
• [56] Immunization (83093df7-a1e4-b827-9ba3-181c9443b46b): Immunization: HPV, quadrivalent (status: completed, CVX: 62, source: LAWRENCE GENERAL HOSPITAL)
• [57] MedicationRequest (83093df7-a1e4-b827-bd25-484d0a73f2f6): Medication: Penicillin V Potassium 250 MG Oral Tablet (status: completed, type: prescribed, reason: Acute viral pharyngitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 834061)
• [62] MedicationAdministration (09546734-0c79-08fd-9dc8-d3f287dacc61): Medication: sodium fluoride 0.0272 MG/MG Oral Gel (status: completed, type: inpatient/administered, reason: Gingivitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 1535362)
• [63] MedicationRequest (83093df7-a1e4-b827-770c-76925281ec35): Medication: sodium fluoride 0.0272 MG/MG Oral Gel (status: completed, type: prescribed, reason: Gingivitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 1535362)

### Clinical Problem List & Data Quality Findings [67]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [63]
- **7 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 7 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Limited social contact (finding), Victim of intimate partner abuse (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [9] [10] [78] [79] [80] [81] [82] [83] [84] [85]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [27]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [28]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [29]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [30]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [86]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,076 tokens)
- **52 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 52 exact duplicate note attachments while preserving 52 unique clinical narratives. 
- **143 Raw Lab Measurements Consolidated Across 24 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [28] [29] [32]
- **12 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 12 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [45] [70] [71] [76] [77] [47]
- **176 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 176 billing/administrative resources (Claim: 60, Device(clinic_equipment_retained): 8, ExplanationOfBenefit: 60, Medication: 4, Provenance: 1, SupplyDelivery: 43) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [9] Condition (4be6b5fb-2a19-943a-7617-5e43e4960522): Condition: Victim of intimate partner abuse (finding) (status: active, onset: 2026-03-17, SNOMED: 706893006)
• [10] Condition (4be6b5fb-2a19-943a-09e1-bbaa61fbdd16): Condition: Limited social contact (finding) (status: active, onset: 2026-06-23, SNOMED: 423315002)
• [27] Observation (4be6b5fb-2a19-943a-bd5f-647eb1eec07d): Finding — Creatinine [Mass/volume] in Blood: 0.93 mg/dL (initial 1.03 on 2017-03-07 -> latest 0.93 on 2026-06-23; range 0.93 to 1.24 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: down)
• [28] Observation (4be6b5fb-2a19-943a-bd7c-e31ee1449333): Finding — Hemoglobin A1c (HbA1c): 6.17 % (initial 6.03 on 2017-03-07 -> latest 6.17 on 2026-06-23; range 5.85 to 6.37 % over n=13 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)
• [29] Observation (4be6b5fb-2a19-943a-7c86-4b824f3bf565): Finding — Glucose (Blood/Serum): 68.65 mg/dL (initial 66.2 on 2017-03-07 -> latest 68.65 on 2026-06-23; range 66.2 to 99.99 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)
• [30] Observation (4be6b5fb-2a19-943a-6433-bfaad02aa4d4): Finding — Potassium (Blood/Serum): 5.11 mmol/L (initial 4.78 on 2017-03-07 -> latest 5.11 on 2026-06-23; range 3.87 to 5.16 mmol/L over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)

### Clinical Problem List & Data Quality Findings
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [63]
- **7 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 7 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Limited social contact (finding), Victim of intimate partner abuse (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [9] [10] [78] [79] [80] [81] [82] [83] [84] [85]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [27]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [28]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [29]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [30]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [86]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,076 tokens)
- **52 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 52 exact duplicate note attachments while preserving 52 unique clinical narratives. 
- **143 Raw Lab Measurements Consolidated Across 24 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [28] [29] [32]
- **12 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 12 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [45] [70] [71] [76] [77] [47]
- **176 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 176 billing/administrative resources (Claim: 60, Device(clinic_equipment_retained): 8, ExplanationOfBenefit: 60, Medication: 4, Provenance: 1, SupplyDelivery: 43) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [9] Condition (4be6b5fb-2a19-943a-7617-5e43e4960522): Condition: Victim of intimate partner abuse (finding) (status: active, onset: 2026-03-17, SNOMED: 706893006)
• [10] Condition (4be6b5fb-2a19-943a-09e1-bbaa61fbdd16): Condition: Limited social contact (finding) (status: active, onset: 2026-06-23, SNOMED: 423315002)
• [27] Observation (4be6b5fb-2a19-943a-bd5f-647eb1eec07d): Finding — Creatinine [Mass/volume] in Blood: 0.93 mg/dL (initial 1.03 on 2017-03-07 -> latest 0.93 on 2026-06-23; range 0.93 to 1.24 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: down)
• [28] Observation (4be6b5fb-2a19-943a-bd7c-e31ee1449333): Finding — Hemoglobin A1c (HbA1c): 6.17 % (initial 6.03 on 2017-03-07 -> latest 6.17 on 2026-06-23; range 5.85 to 6.37 % over n=13 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)
• [29] Observation (4be6b5fb-2a19-943a-7c86-4b824f3bf565): Finding — Glucose (Blood/Serum): 68.65 mg/dL (initial 66.2 on 2017-03-07 -> latest 68.65 on 2026-06-23; range 66.2 to 99.99 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)
• [30] Observation (4be6b5fb-2a19-943a-6433-bfaad02aa4d4): Finding — Potassium (Blood/Serum): 5.11 mmol/L (initial 4.78 on 2017-03-07 -> latest 5.11 on 2026-06-23; range 3.87 to 5.16 mmol/L over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: up)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [51]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [54]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [76]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [64] [72] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [51]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [53]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [55]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [56]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [140]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [59] [60]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,096 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [55] [58] [52] [53]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [51] Observation (5693c080-f485-91e7-0b17-9dbdd024f14d): Finding — Glomerular filtration rate (eGFR): 47.95 mL/min/{1.73_m2} (initial 124.48 on 2017-01-01 -> latest 47.95 on 2026-08-16; range 5.49 to 124.48 mL/min/{1.73_m2} over n=114 measurements, first recorded 2017-01-01 through 2026-08-16, trend: down)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [51]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [54]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [76]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [64] [72] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [51]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [53]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [55]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [56]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [140]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [59] [60]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,096 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [55] [58] [52] [53]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [51] Observation (5693c080-f485-91e7-0b17-9dbdd024f14d): Finding — Glomerular filtration rate (eGFR): 47.95 mL/min/{1.73_m2} (initial 124.48 on 2017-01-01 -> latest 47.95 on 2026-08-16; range 5.49 to 124.48 mL/min/{1.73_m2} over n=114 measurements, first recorded 2017-01-01 through 2026-08-16, trend: down)

### Clinical Problem List & Data Quality Findings [86]
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [51]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [54]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [76]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [64] [72] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [51]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [53]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [55]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [56]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [140]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [59] [60]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,096 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [55] [58] [52] [53]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [51] Observation (5693c080-f485-91e7-0b17-9dbdd024f14d): Finding — Glomerular filtration rate (eGFR): 47.95 mL/min/{1.73_m2} (initial 124.48 on 2017-01-01 -> latest 47.95 on 2026-08-16; range 5.49 to 124.48 mL/min/{1.73_m2} over n=114 measurements, first recorded 2017-01-01 through 2026-08-16, trend: down)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [51]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [54]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [76]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [64] [72] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [51]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [53]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [55]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [56]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [140]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [59] [60]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,096 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [55] [58] [52] [53]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [51] Observation (5693c080-f485-91e7-0b17-9dbdd024f14d): Finding — Glomerular filtration rate (eGFR): 47.95 mL/min/{1.73_m2} (initial 124.48 on 2017-01-01 -> latest 47.95 on 2026-08-16; range 5.49 to 124.48 mL/min/{1.73_m2} over n=114 measurements, first recorded 2017-01-01 through 2026-08-16, trend: down)

### Clinical Problem List & Data Quality Findings
- **Duplicate Same-Day COVID-19 Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): COVID-19 immunization entries (2022-01-17 [LAWRENCE GENERAL HOSPITAL], 2022-01-18 [Bartell Drugs #42 - Seattle]): duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [60] [65]
- **ACIP Immunization Schedule Anomaly: HPV Series (1 doses)** (CDC ACIP Schedule Anomaly): HPV immunization entries (2022-05-02 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [56] [73] [74]
- **Duplicate Same-Day Influenza Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): Influenza immunization entries (2026-01-26 [NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC], 2026-01-28 [WA State IIS Immunization Registry (Pharmacy Feed)]): duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [15] [26]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `17.03 g/dL` (`2020-12-28T21:08`) $\to$ range `12.18–17.03` $\to$ **latest `12.18 g/dL` (`2026-01-26T21:08`)** [decreasing / trending down] [18]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,057 tokens)
- **26 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 26 exact duplicate note attachments while preserving 26 unique clinical narratives. 
- **22 Raw Lab Measurements Consolidated Across 11 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. 
- **11 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 11 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [51] [63] [64] [70] [71] [57]
- **102 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 102 billing/administrative resources (Claim: 34, Device(clinic_equipment_retained): 9, ExplanationOfBenefit: 34, Medication: 3, Provenance: 1, SupplyDelivery: 21) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): COVID-19 Immunization resources (CVX 208 on 2022-01-17, CVX 208 on 2022-01-18). duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18). | Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2026-01-26, CVX 140 on 2026-01-28). duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28).

• [15] Immunization (imm-iis-byron-flu-2026): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: WA State IIS Immunization Registry (Pharmacy Feed))
• [18] Observation (83093df7-a1e4-b827-1b30-2e75a7463d5d): Finding — Hemoglobin [Mass/volume] in Blood: 12.18 g/dL (initial 17.03 on 2020-12-28 -> latest 12.18 on 2026-01-26; range 12.18 to 17.03 g/dL over n=2 measurements, first recorded 2020-12-28 through 2026-01-26, trend: down)
• [26] Immunization (83093df7-a1e4-b827-159b-4271c06f5179): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [51] MedicationRequest (83093df7-a1e4-b827-0579-9a52cff34a9a): Medication: sodium fluoride 0.0272 MG/MG Oral Gel (status: completed, type: prescribed, reason: Gingivitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 1535362)
• [56] Immunization (83093df7-a1e4-b827-9ba3-181c9443b46b): Immunization: HPV, quadrivalent (status: completed, CVX: 62, source: LAWRENCE GENERAL HOSPITAL)
• [57] MedicationRequest (83093df7-a1e4-b827-bd25-484d0a73f2f6): Medication: Penicillin V Potassium 250 MG Oral Tablet (status: completed, type: prescribed, reason: Acute viral pharyngitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 834061)

### Clinical Problem List & Data Quality Findings
- **Duplicate Same-Day COVID-19 Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): COVID-19 immunization entries (2022-01-17 [LAWRENCE GENERAL HOSPITAL], 2022-01-18 [Bartell Drugs #42 - Seattle]): duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [60] [65]
- **ACIP Immunization Schedule Anomaly: HPV Series (1 doses)** (CDC ACIP Schedule Anomaly): HPV immunization entries (2022-05-02 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [56] [73] [74]
- **Duplicate Same-Day Influenza Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): Influenza immunization entries (2026-01-26 [NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC], 2026-01-28 [WA State IIS Immunization Registry (Pharmacy Feed)]): duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [15] [26]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `17.03 g/dL` (`2020-12-28T21:08`) $\to$ range `12.18–17.03` $\to$ **latest `12.18 g/dL` (`2026-01-26T21:08`)** [decreasing / trending down] [18]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,057 tokens)
- **26 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 26 exact duplicate note attachments while preserving 26 unique clinical narratives. 
- **22 Raw Lab Measurements Consolidated Across 11 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. 
- **11 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 11 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [51] [63] [64] [70] [71] [57]
- **102 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 102 billing/administrative resources (Claim: 34, Device(clinic_equipment_retained): 9, ExplanationOfBenefit: 34, Medication: 3, Provenance: 1, SupplyDelivery: 21) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): COVID-19 Immunization resources (CVX 208 on 2022-01-17, CVX 208 on 2022-01-18). duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18). | Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2026-01-26, CVX 140 on 2026-01-28). duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28).

• [15] Immunization (imm-iis-byron-flu-2026): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: WA State IIS Immunization Registry (Pharmacy Feed))
• [18] Observation (83093df7-a1e4-b827-1b30-2e75a7463d5d): Finding — Hemoglobin [Mass/volume] in Blood: 12.18 g/dL (initial 17.03 on 2020-12-28 -> latest 12.18 on 2026-01-26; range 12.18 to 17.03 g/dL over n=2 measurements, first recorded 2020-12-28 through 2026-01-26, trend: down)
• [26] Immunization (83093df7-a1e4-b827-159b-4271c06f5179): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [51] MedicationRequest (83093df7-a1e4-b827-0579-9a52cff34a9a): Medication: sodium fluoride 0.0272 MG/MG Oral Gel (status: completed, type: prescribed, reason: Gingivitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 1535362)
• [56] Immunization (83093df7-a1e4-b827-9ba3-181c9443b46b): Immunization: HPV, quadrivalent (status: completed, CVX: 62, source: LAWRENCE GENERAL HOSPITAL)
• [57] MedicationRequest (83093df7-a1e4-b827-bd25-484d0a73f2f6): Medication: Penicillin V Potassium 250 MG Oral Tablet (status: completed, type: prescribed, reason: Acute viral pharyngitis (disorder), source: LAWRENCE GENERAL HOSPITAL, RxNorm: 834061)

### Clinical Problem List & Data Quality Findings
- **Active vs. Resolved Status Conflict: Chronic sinusitis (disorder)** (Cross-Clinic Condition Status Conflict): Cross-organization records disagree on the clinical status of Chronic sinusitis (disorder): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. Conflict note: status_conflict: Chronic sinusitis (disorder) marked ACTIVE (onset 2008-02-29) but also recorded as RESOLVED on 2024-09-10. *Recommendation:* Verify whether the condition resolved following specialist treatment and update the primary care active problem list. [6] [60]
- **Duplicate Active Ingredient Prescriptions (lisinopril 10 MG Oral Tablet vs. Prinivil 10 MG Oral Tablet [lisinopril])** (Brand vs. Generic Duplicate Therapy): Detected overlapping or interacting active medication orders across sources (SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic): lisinopril 10 MG Oral Tablet (2026-03-17) [SeaMar Community Health Primary Care]; Prinivil 10 MG Oral Tablet [lisinopril] (2026-05-12) [UW Medicine Cardiology Clinic]. Flag: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [11] [12]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [65]
- **7 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 7 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Limited social contact (finding), Victim of intimate partner abuse (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [9] [10] [78] [79] [80] [81] [82] [83] [84] [85]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [29]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [30]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [31]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [32]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [86]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,056 tokens)
- **52 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 52 exact duplicate note attachments while preserving 52 unique clinical narratives. 
- **143 Raw Lab Measurements Consolidated Across 24 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [30] [31] [34]
- **12 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 12 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [47] [72] [73] [77] [49] [76]
- **176 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 176 billing/administrative resources (Claim: 60, Device(clinic_equipment_retained): 8, ExplanationOfBenefit: 60, Medication: 4, Provenance: 1, SupplyDelivery: 43) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-active-vs-resolved-01: Cross-organization Condition.clinicalStatus discrepancy for Chronic sinusitis (disorder) (SNOMED 40055000): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (lisinopril 10 MG Oral Tablet [RxNorm 314076], Prinivil 10 MG Oral Tablet [lisinopril] [RxNorm 206765]) across SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [6] Condition (4be6b5fb-2a19-943a-19f7-35a11a488712): Condition: Chronic sinusitis (disorder) (status: active, onset: 2008-02-29, SNOMED: 40055000)
• [9] Condition (4be6b5fb-2a19-943a-7617-5e43e4960522): Condition: Victim of intimate partner abuse (finding) (status: active, onset: 2026-03-17, SNOMED: 706893006)
• [10] Condition (4be6b5fb-2a19-943a-09e1-bbaa61fbdd16): Condition: Limited social contact (finding) (status: active, onset: 2026-06-23, SNOMED: 423315002)
• [11] MedicationRequest (med-pcp-lamar-lisinopril): Medication: lisinopril 10 MG Oral Tablet (status: active, type: prescribed, source: SeaMar Community Health Primary Care, RxNorm: 314076)
• [12] MedicationRequest (med-cardio-lamar-prinivil): Medication: Prinivil 10 MG Oral Tablet [lisinopril] (status: active, type: prescribed, source: UW Medicine Cardiology Clinic, RxNorm: 206765)
• [29] Observation (4be6b5fb-2a19-943a-bd5f-647eb1eec07d): Finding — Creatinine [Mass/volume] in Blood: 0.93 mg/dL (initial 1.03 on 2017-03-07 -> latest 0.93 on 2026-06-23; range 0.93 to 1.24 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: down)

### Clinical Problem List & Data Quality Findings
- **Active vs. Resolved Status Conflict: Chronic sinusitis (disorder)** (Cross-Clinic Condition Status Conflict): Cross-organization records disagree on the clinical status of Chronic sinusitis (disorder): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. Conflict note: status_conflict: Chronic sinusitis (disorder) marked ACTIVE (onset 2008-02-29) but also recorded as RESOLVED on 2024-09-10. *Recommendation:* Verify whether the condition resolved following specialist treatment and update the primary care active problem list. [6] [60]
- **Duplicate Active Ingredient Prescriptions (lisinopril 10 MG Oral Tablet vs. Prinivil 10 MG Oral Tablet [lisinopril])** (Brand vs. Generic Duplicate Therapy): Detected overlapping or interacting active medication orders across sources (SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic): lisinopril 10 MG Oral Tablet (2026-03-17) [SeaMar Community Health Primary Care]; Prinivil 10 MG Oral Tablet [lisinopril] (2026-05-12) [UW Medicine Cardiology Clinic]. Flag: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [11] [12]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [65]
- **7 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 7 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Limited social contact (finding), Victim of intimate partner abuse (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [9] [10] [78] [79] [80] [81] [82] [83] [84] [85]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [29]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [30]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [31]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [32]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [86]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,056 tokens)
- **52 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 52 exact duplicate note attachments while preserving 52 unique clinical narratives. 
- **143 Raw Lab Measurements Consolidated Across 24 Canonical Analytes:** Identified 0 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (none) and 0 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [30] [31] [34]
- **12 Historical Prescription Renewals Folded into 4 Ingredient Spans:** Condensed 12 stopped/completed MedicationRequest renewal entries into 4 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. [47] [72] [73] [77] [49] [76]
- **176 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 176 billing/administrative resources (Claim: 60, Device(clinic_equipment_retained): 8, ExplanationOfBenefit: 60, Medication: 4, Provenance: 1, SupplyDelivery: 43) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-active-vs-resolved-01: Cross-organization Condition.clinicalStatus discrepancy for Chronic sinusitis (disorder) (SNOMED 40055000): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (lisinopril 10 MG Oral Tablet [RxNorm 314076], Prinivil 10 MG Oral Tablet [lisinopril] [RxNorm 206765]) across SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [6] Condition (4be6b5fb-2a19-943a-19f7-35a11a488712): Condition: Chronic sinusitis (disorder) (status: active, onset: 2008-02-29, SNOMED: 40055000)
• [9] Condition (4be6b5fb-2a19-943a-7617-5e43e4960522): Condition: Victim of intimate partner abuse (finding) (status: active, onset: 2026-03-17, SNOMED: 706893006)
• [10] Condition (4be6b5fb-2a19-943a-09e1-bbaa61fbdd16): Condition: Limited social contact (finding) (status: active, onset: 2026-06-23, SNOMED: 423315002)
• [11] MedicationRequest (med-pcp-lamar-lisinopril): Medication: lisinopril 10 MG Oral Tablet (status: active, type: prescribed, source: SeaMar Community Health Primary Care, RxNorm: 314076)
• [12] MedicationRequest (med-cardio-lamar-prinivil): Medication: Prinivil 10 MG Oral Tablet [lisinopril] (status: active, type: prescribed, source: UW Medicine Cardiology Clinic, RxNorm: 206765)
• [29] Observation (4be6b5fb-2a19-943a-bd5f-647eb1eec07d): Finding — Creatinine [Mass/volume] in Blood: 0.93 mg/dL (initial 1.03 on 2017-03-07 -> latest 0.93 on 2026-06-23; range 0.93 to 1.24 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: down)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [53]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [56]
- **Duplicate Active Ingredient Prescriptions (Clopidogrel 75 MG Oral Tablet vs. Plavix 75 MG Oral Tablet [clopidogrel])** (Brand vs. Generic Duplicate Therapy): Detected overlapping or interacting active medication orders across sources (LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute): Clopidogrel 75 MG Oral Tablet (2023-09-06) [LAWRENCE GENERAL HOSPITAL]; Plavix 75 MG Oral Tablet [clopidogrel] (2026-06-07) [MultiCare Pulse Heart Institute]. Flag: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [24] [30]
- **Concurrent Active Statin Prescriptions (Simvastatin 20 MG Oral Tablet + Lipitor 40 MG Oral Tablet [atorvastatin])** (Therapeutic Class Duplication): Detected overlapping or interacting active medication orders across sources (LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute): Simvastatin 20 MG Oral Tablet (2023-09-06) [LAWRENCE GENERAL HOSPITAL]; Lipitor 40 MG Oral Tablet [atorvastatin] (2026-06-07) [MultiCare Pulse Heart Institute]. Flag: duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [25] [31]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [79]
- **Duplicate Same-Day Influenza Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): Influenza immunization entries (2025-09-28 [ACADEMY MANOR], 2025-09-30 [WA State IIS Immunization Registry]): duplicate_candidate: Influenza recorded 2d apart (2025-09-28 vs 2025-09-30). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [76] [77]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [66] [74] [90] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [53]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [55]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [56]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [57]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [58]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [139]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [61] [62]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,066 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [57] [60] [54] [55]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (Clopidogrel 75 MG Oral Tablet [RxNorm 309362], Plavix 75 MG Oral Tablet [clopidogrel] [RxNorm 213169]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel]). | Rule wahs-kb-rx-duplicate-statin-01: Active MedicationRequest conflict (Simvastatin 20 MG Oral Tablet [RxNorm 312961], Lipitor 40 MG Oral Tablet [atorvastatin] [RxNorm 617311]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2025-09-28, CVX 140 on 2025-09-30). duplicate_candidate: Influenza recorded 2d apart (2025-09-28 vs 2025-09-30). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [24] MedicationRequest (5693c080-f485-91e7-049d-0016c58b2394): Medication: Clopidogrel 75 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 309362)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [53]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [56]
- **Duplicate Active Ingredient Prescriptions (Clopidogrel 75 MG Oral Tablet vs. Plavix 75 MG Oral Tablet [clopidogrel])** (Brand vs. Generic Duplicate Therapy): Detected overlapping or interacting active medication orders across sources (LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute): Clopidogrel 75 MG Oral Tablet (2023-09-06) [LAWRENCE GENERAL HOSPITAL]; Plavix 75 MG Oral Tablet [clopidogrel] (2026-06-07) [MultiCare Pulse Heart Institute]. Flag: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [24] [30]
- **Concurrent Active Statin Prescriptions (Simvastatin 20 MG Oral Tablet + Lipitor 40 MG Oral Tablet [atorvastatin])** (Therapeutic Class Duplication): Detected overlapping or interacting active medication orders across sources (LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute): Simvastatin 20 MG Oral Tablet (2023-09-06) [LAWRENCE GENERAL HOSPITAL]; Lipitor 40 MG Oral Tablet [atorvastatin] (2026-06-07) [MultiCare Pulse Heart Institute]. Flag: duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [25] [31]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [79]
- **Duplicate Same-Day Influenza Immunization Records Across Sources** (WA IIS vs. Clinic Registry Duplicate): Influenza immunization entries (2025-09-28 [ACADEMY MANOR], 2025-09-30 [WA State IIS Immunization Registry]): duplicate_candidate: Influenza recorded 2d apart (2025-09-28 vs 2025-09-30). *Recommendation:* Deduplicate same-day clinic and WA IIS registry feeds into a single canonical administration event. [76] [77]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [66] [74] [90] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [53]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [55]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [56]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [57]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [58]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [139]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [61] [62]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,066 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [57] [60] [54] [55]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (Clopidogrel 75 MG Oral Tablet [RxNorm 309362], Plavix 75 MG Oral Tablet [clopidogrel] [RxNorm 213169]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel]). | Rule wahs-kb-rx-duplicate-statin-01: Active MedicationRequest conflict (Simvastatin 20 MG Oral Tablet [RxNorm 312961], Lipitor 40 MG Oral Tablet [atorvastatin] [RxNorm 617311]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2025-09-28, CVX 140 on 2025-09-30). duplicate_candidate: Influenza recorded 2d apart (2025-09-28 vs 2025-09-30). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [24] MedicationRequest (5693c080-f485-91e7-049d-0016c58b2394): Medication: Clopidogrel 75 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 309362)

### High-Acuity Inpatient / Procedural Summary (2023-11-20 through 2023-11-28): Insertion of catheter into artery (procedure) [83]
Maurice742 Marcos263 Auer97 was evaluated during 2023-11-20 through 2023-11-28 (Hospital admission (procedure)) with documented diagnoses including History of coronary artery bypass grafting (situation). Key procedures and interventions performed during this episode: Insertion of catheter into artery (procedure), Administration of anesthesia for procedure (procedure), Intubation (procedure), Pulmonary catheterization with Swan-Ganz catheter (procedure), Preparation of patient for procedure (regime/therapy). Documented implantable or patient-carried devices on chart: Blood glucose meter (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Operating room (environment). Episode and discharge medications recorded in window: cefazolin 2000 MG Injection, 1 ML heparin sodium, porcine 5000 UNT/ML Injection, 25 ML protamine sulfate (USP) 10 MG/ML Injection. [21] [30] [31] [32] [33] [81] [21] [91] [92] [93] [94] [95]

- **Key Procedures:** Insertion of catheter into artery (procedure), Administration of anesthesia for procedure (procedure), Intubation (procedure), Pulmonary catheterization with Swan-Ganz catheter (procedure), Preparation of patient for procedure (regime/therapy), Cannulation (procedure), Cardiopulmonary bypass operation (procedure), Placement of aortic cross clamp (procedure)
- **Perioperative / Episode Medications:** cefazolin 2000 MG Injection (2023-11-20), cefazolin 2000 MG Injection (2023-11-20), 1 ML heparin sodium, porcine 5000 UNT/ML Injection (2023-11-20), 1 ML heparin sodium, porcine 5000 UNT/ML Injection (2023-11-20), 25 ML protamine sulfate (USP) 10 MG/ML Injection (2023-11-20), 25 ML protamine sulfate (USP) 10 MG/ML Injection (2023-11-20), 2 ML Ondansetron 2 MG/ML Injection (2023-11-20), 2 ML Ondansetron 2 MG/ML Injection (2023-11-20)
- **Implantable / Patient Devices:** Blood glucose meter (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Operating room (environment)

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [21] Condition (5693c080-f485-91e7-f448-62985ae4c285): Condition: History of coronary artery bypass grafting (situation) (status: active, onset: 2023-11-20, SNOMED: 399261000)
• [30] Device (5693c080-f485-91e7-01dc-b399ddbef2cb): Device: Blood glucose meter (physical object) (status: active)
• [31] Device (5693c080-f485-91e7-0e82-6869dcffc049): Device: Dental x-ray system (physical object) (status: active)
• [32] Device (5693c080-f485-91e7-6953-d3fb2d6cadcf): Device: Dental x-ray system (physical object) (status: active)
• [33] Device (5693c080-f485-91e7-40b5-a89993a05ae9): Device: Home-use sleep apnea recording system (physical object) (status: active)
• [81] Encounter (5693c080-f485-91e7-df4a-bdb8522d08d3): Encounter: Patient transfer to intensive care unit (procedure) (class: IMP, discharged: 2023-11-27, reason: History of coronary artery bypass grafting (situation), facility: Fitchburg Outpatient Clinic)

### Directed Clinical Summary (Patient Self-Access Full Health Summary)
- **Active Conditions:** Educated to high school level (finding), Prediabetes (finding), Body mass index 30+ - obesity (finding), Anemia (disorder), Impacted molars (disorder), Essential hypertension (disorder), Metabolic syndrome X (disorder), Has a criminal record (finding), Chronic kidney disease stage 1 (disorder), Disorder of kidney due to diabetes mellitus (disorder), Chronic kidney disease stage 2 (disorder), Microalbuminuria due to type 2 diabetes mellitus (disorder), Chronic kidney disease stage 3 (disorder), Proteinuria due to type 2 diabetes mellitus (disorder), Sleep disorder (disorder), Sleep apnea (disorder), Ischemic heart disease (disorder), Abnormal findings diagnostic imaging heart+coronary circulat (finding), History of coronary artery bypass grafting (situation), Gingivitis (disorder), Part-time employment (finding) [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [74] [75] [76] [77] [78] [86] [87] [88] [89] [90] [91] [92] [93] [94] [95]
- **Active Medications:** Clopidogrel 75 MG Oral Tablet, Simvastatin 20 MG Oral Tablet, 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet, Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray, insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin], Hydrochlorothiazide 25 MG Oral Tablet
- **Patient Devices:** Blood glucose meter (physical object), Dental x-ray system (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Operating room (environment), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object)
- **Sensitive SDOH Status:** Victim of intimate partner abuse (finding), Has a criminal record (finding), Unhealthy alcohol drinking behavior (finding), Social isolation (finding), Limited social contact (finding), Social isolation (finding), Reports of violence in the environment (finding), Social isolation (finding), Victim of intimate partner abuse (finding), Social isolation (finding), Victim of intimate partner abuse (finding), Social isolation (finding), Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10], Drug Abuse Screening Test-10 [DAST-10]

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [3] Condition (5693c080-f485-91e7-32a9-b5480ad5e937): Condition: Educated to high school level (finding) (status: active, onset: 1991-05-20, SNOMED: 473461003)
• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [5] Condition (5693c080-f485-91e7-38d9-63f819020943): Condition: Body mass index 30+ - obesity (finding) (status: active, onset: 1995-05-28, SNOMED: 162864005)
• [6] Condition (5693c080-f485-91e7-a121-1912e8e4f3f1): Condition: Anemia (disorder) (status: active, onset: 1998-05-31, SNOMED: 271737000)
• [7] Condition (5693c080-f485-91e7-44fb-a1a146a40bda): Condition: Impacted molars (disorder) (status: active, onset: 2003-12-25, SNOMED: 196416002)
• [8] Condition (5693c080-f485-91e7-6688-9f89a7832b74): Condition: Essential hypertension (disorder) (status: active, onset: 2013-03-31, SNOMED: 59621000)

### Grounded Patient Health Summary: Maurice742 Marcos263 Auer97 (External / Specialist / School Share (SDOH Privacy-Redacted)) [14]
- **Demographics & Anchor Date:** Birth date `1973-03-25`, reference date `2026-08-17` [1] [3] [4] [5] [6]
- **Active Problem List (20):** Educated to high school level (finding), Prediabetes (finding), Body mass index 30+ - obesity (finding), Anemia (disorder), Impacted molars (disorder), Essential hypertension (disorder), Metabolic syndrome X (disorder), Chronic kidney disease stage 1 (disorder), Disorder of kidney due to diabetes mellitus (disorder), Chronic kidney disease stage 2 (disorder), Microalbuminuria due to type 2 diabetes mellitus (disorder), Chronic kidney disease stage 3 (disorder), Proteinuria due to type 2 diabetes mellitus (disorder), Sleep disorder (disorder), Sleep apnea (disorder), Ischemic heart disease (disorder), Abnormal findings diagnostic imaging heart+coronary circulat (finding), History of coronary artery bypass grafting (situation), Gingivitis (disorder), Part-time employment (finding)
- **Active Medications (6):** Clopidogrel 75 MG Oral Tablet, Simvastatin 20 MG Oral Tablet, 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet, Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray, insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin], Hydrochlorothiazide 25 MG Oral Tablet
- **Data Quality Alerts Flagged:** `4` clinical reconciliation findings (3 high-severity)
- **Longitudinal Trajectories:** Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M: 47.95 mL/min/{1.73_m2}, Creatinine [Mass/volume] in Serum or Plasma: 1.99 mg/dL, Hemoglobin A1c/Hemoglobin.total in Blood: 3.0 %, Glucose [Mass/volume] in Serum or Plasma: 67.68 mg/dL, Potassium [Moles/volume] in Serum or Plasma: 4.74 mmol/L

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='external_share' (redacted_for_privacy=202).

• [1] Patient (5693c080-f485-91e7-54b9-ad9a8c12af62): Patient: Maurice742 Marcos263 Auer97, DOB: 1973-03-25, Gender: male, Age: 53y (as of 2026-08-17), Language: English (United States)
• [3] Condition (5693c080-f485-91e7-32a9-b5480ad5e937): Condition: Educated to high school level (finding) (status: active, onset: 1991-05-20, SNOMED: 473461003)
• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [5] Condition (5693c080-f485-91e7-38d9-63f819020943): Condition: Body mass index 30+ - obesity (finding) (status: active, onset: 1995-05-28, SNOMED: 162864005)
• [6] Condition (5693c080-f485-91e7-a121-1912e8e4f3f1): Condition: Anemia (disorder) (status: active, onset: 1998-05-31, SNOMED: 271737000)

### Grounded Patient Health Summary: Lamar193 Oswaldo857 Beer512 (Patient Self-Access Full Health Summary)
- **Demographics & Anchor Date:** Birth date `1971-02-16`, reference date `2026-07-08` [1] [3] [4] [5] [6]
- **Active Problem List (8):** Received higher education (finding), Prediabetes (finding), Anemia (disorder), Chronic sinusitis (disorder), Loss of teeth (disorder), Full-time employment (finding), Victim of intimate partner abuse (finding), Limited social contact (finding)
- **Active Medications (0):** None active
- **Data Quality Alerts Flagged:** `2` clinical reconciliation findings (0 high-severity)
- **Longitudinal Trajectories:** Creatinine [Mass/volume] in Blood: 0.93 mg/dL, Hemoglobin A1c/Hemoglobin.total in Blood: 6.17 %, Glucose [Mass/volume] in Blood: 68.65 mg/dL, Potassium [Moles/volume] in Blood: 5.11 mmol/L, Diastolic Blood Pressure: 75.0 mm[Hg]

Clinician Technical Note: Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [1] Patient (4be6b5fb-2a19-943a-9249-7068445be4cc): Patient: Lamar193 Oswaldo857 Beer512, DOB: 1971-02-16, Gender: male, Age: 55y (as of 2026-07-08), Language: English (United States)
• [3] Condition (4be6b5fb-2a19-943a-c61d-55c53533ee38): Condition: Received higher education (finding) (status: active, onset: 1989-04-11, SNOMED: 224299000)
• [4] Condition (4be6b5fb-2a19-943a-7d72-3e9579eaf9c0): Condition: Prediabetes (finding) (status: active, onset: 1993-04-20, SNOMED: 714628002)
• [5] Condition (4be6b5fb-2a19-943a-be24-f21216f23853): Condition: Anemia (disorder) (status: active, onset: 1996-04-23, SNOMED: 271737000)
• [6] Condition (4be6b5fb-2a19-943a-19f7-35a11a488712): Condition: Chronic sinusitis (disorder) (status: active, onset: 2008-02-29, SNOMED: 40055000)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [10] [12] [14] [50]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [53]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [75]
- **32 Sensitive SDOH / Behavioral Health Records (REDACTED in External Share)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): In 'external_share' mode, all 202 privacy-sensitive SDOH or behavioral health items were automatically stripped from the prompt context and recorded in the Privacy Manifest under 42 CFR Part 2 and the WA My Health My Data Act. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. 

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [50]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [52]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [53]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [55]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [90]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [58] [59]

### Directed Clinical Summary (External / Specialist / School Share (SDOH Privacy-Redacted))
- **Active Conditions:** Educated to high school level (finding), Prediabetes (finding), Body mass index 30+ - obesity (finding), Anemia (disorder), Impacted molars (disorder), Essential hypertension (disorder), Metabolic syndrome X (disorder), Chronic kidney disease stage 1 (disorder), Disorder of kidney due to diabetes mellitus (disorder), Chronic kidney disease stage 2 (disorder), Microalbuminuria due to type 2 diabetes mellitus (disorder), Chronic kidney disease stage 3 (disorder), Proteinuria due to type 2 diabetes mellitus (disorder), Sleep disorder (disorder), Sleep apnea (disorder), Ischemic heart disease (disorder), Abnormal findings diagnostic imaging heart+coronary circulat (finding), History of coronary artery bypass grafting (situation), Gingivitis (disorder), Part-time employment (finding) [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [73] [74] [75] [76] [77] [85] [86] [87] [88] [89] [91] [92] [93] [94] [95]
- **Active Medications:** Clopidogrel 75 MG Oral Tablet, Simvastatin 20 MG Oral Tablet, 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet, Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray, insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin], Hydrochlorothiazide 25 MG Oral Tablet
- **Patient Devices:** Blood glucose meter (physical object), Dental x-ray system (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Operating room (environment), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Appliance for sleep apnea (physical object), Dental x-ray system (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object), Appliance for sleep apnea (physical object)
- **Sensitive SDOH Status:** Redacted (202 items excluded for external sharing)

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='external_share' (redacted_for_privacy=202).

• [3] Condition (5693c080-f485-91e7-32a9-b5480ad5e937): Condition: Educated to high school level (finding) (status: active, onset: 1991-05-20, SNOMED: 473461003)
• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [5] Condition (5693c080-f485-91e7-38d9-63f819020943): Condition: Body mass index 30+ - obesity (finding) (status: active, onset: 1995-05-28, SNOMED: 162864005)
• [6] Condition (5693c080-f485-91e7-a121-1912e8e4f3f1): Condition: Anemia (disorder) (status: active, onset: 1998-05-31, SNOMED: 271737000)
• [7] Condition (5693c080-f485-91e7-44fb-a1a146a40bda): Condition: Impacted molars (disorder) (status: active, onset: 2003-12-25, SNOMED: 196416002)
• [8] Condition (5693c080-f485-91e7-6688-9f89a7832b74): Condition: Essential hypertension (disorder) (status: active, onset: 2013-03-31, SNOMED: 59621000)

### Immunization History & ACIP Schedule Audit (18 doses in view)
- `2016-12-05`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [74]
- `2017-12-11`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [75]
- `2018-12-17`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [76]
- `2019-12-23`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [77]
- `2020-12-28`: **Tdap** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [78]
- `2020-12-28`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [79]
- `2020-12-28`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [80]
- `2020-12-28`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [81]
- `2021-12-27`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) [68]
- `2022-01-03`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [65]
- `2022-01-03`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [66]
- `2022-01-17`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) [64]
- `2022-05-02`: **HPV, quadrivalent** (source: `LAWRENCE GENERAL HOSPITAL`) — **[acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15]** [56]
- `2023-01-09`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [53]
- `2024-01-15`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [43]
- `2025-01-20`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [39]
- `2026-01-26`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [26]
- `2026-01-26`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [27]

Clinician Technical Note: Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15.

• [26] Immunization (83093df7-a1e4-b827-159b-4271c06f5179): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [27] Immunization (83093df7-a1e4-b827-b763-089cd8c363c6): Immunization: meningococcal MCV4P (status: completed, CVX: 114, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [39] Immunization (83093df7-a1e4-b827-6ea6-0974e08a5de5): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [43] Immunization (83093df7-a1e4-b827-495f-09836498a3cb): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [53] Immunization (83093df7-a1e4-b827-b62b-2cd322ef34df): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [56] Immunization (83093df7-a1e4-b827-9ba3-181c9443b46b): Immunization: HPV, quadrivalent (status: completed, CVX: 62, source: LAWRENCE GENERAL HOSPITAL)

### Clinical Problem List & Data Quality Findings
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [63]
- **7 Sensitive SDOH / Behavioral Health Records (REDACTED in External Share)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): In 'external_share' mode, all 36 privacy-sensitive SDOH or behavioral health items were automatically stripped from the prompt context and recorded in the Privacy Manifest under 42 CFR Part 2 and the WA My Health My Data Act. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. 

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [25]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [26]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [27]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [28]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [78]

### Directed Clinical Summary (External / Specialist / School Share (SDOH Privacy-Redacted))
- **Active Conditions:** Received higher education (finding), Prediabetes (finding), Anemia (disorder), Chronic sinusitis (disorder), Loss of teeth (disorder), Full-time employment (finding) [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [52] [55] [59] [60] [63] [64] [65] [67] [68] [72] [79] [80]
- **Active Medications:** None active
- **Patient Devices:** Blood glucose meter (physical object), Home nebulizer (physical object), Operating room (environment), Operating room (environment), Dental x-ray system (physical object), Operating room (environment), Denture, device (physical object), Dental x-ray system (physical object), Dental x-ray system (physical object), Denture, device (physical object), Dental x-ray system (physical object), Dental x-ray system (physical object)
- **Sensitive SDOH Status:** Redacted (36 items excluded for external sharing)

Clinician Technical Note: Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='external_share' (redacted_for_privacy=36).

• [3] Condition (4be6b5fb-2a19-943a-c61d-55c53533ee38): Condition: Received higher education (finding) (status: active, onset: 1989-04-11, SNOMED: 224299000)
• [4] Condition (4be6b5fb-2a19-943a-7d72-3e9579eaf9c0): Condition: Prediabetes (finding) (status: active, onset: 1993-04-20, SNOMED: 714628002)
• [5] Condition (4be6b5fb-2a19-943a-be24-f21216f23853): Condition: Anemia (disorder) (status: active, onset: 1996-04-23, SNOMED: 271737000)
• [6] Condition (4be6b5fb-2a19-943a-19f7-35a11a488712): Condition: Chronic sinusitis (disorder) (status: active, onset: 2008-02-29, SNOMED: 40055000)
• [7] Condition (4be6b5fb-2a19-943a-752d-9383f84c8719): Condition: Loss of teeth (disorder) (status: active, onset: 2018-03-20, SNOMED: 37320007)
• [8] Condition (4be6b5fb-2a19-943a-8569-bc57b5527548): Condition: Full-time employment (finding) (status: active, onset: 2026-03-17, SNOMED: 160903007)

### Clinical Problem List & Data Quality Findings
- **Mutually Exclusive Active CKD Stages simultaneously on Problem List** (Condition Stage Conflict (KDIGO)): Patient has 3 concurrent active Chronic Kidney Disease stage diagnoses (Chronic kidney disease stage 1 (disorder), Chronic kidney disease stage 2 (disorder), Chronic kidney disease stage 3 (disorder)). Under KDIGO 2024 guidelines, a patient can only occupy one current CKD G-stage; earlier stages were never marked resolved when kidney function progressed. Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). *Recommendation:* Reconcile active problem list to retain only the current KDIGO CKD stage supported by persistent eGFR/uACR over >=90 days, and mark prior CKD stage entries as resolved/superseded. [11] [13] [15] [51]
- **Concurrent Active Prediabetes and Type 2 Diabetes Mellitus** (Condition Exclusivity Conflict (ADA)): Problem list carries both active Prediabetes (finding). Under ADA Standards of Care, once Type 2 Diabetes Mellitus (SNOMED 44054006) is established, Prediabetes (SNOMED 714628002) is superseded and should not remain as a separate active problem. Latest HbA1c is 3.0% on 2026-08-16T23:50. *Recommendation:* Archive/resolve the historical Prediabetes Condition resource and confirm glycemic status against recent HbA1c measurements. [4] [54]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2024-04-28 [LAWRENCE GENERAL HOSPITAL]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [76]
- **32 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 32 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Has a criminal record (finding), Limited social contact (finding), Reports of violence in the environment (finding), Social isolation (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [10] [64] [72] [91] [92] [93] [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M** (114 measurements): initial `124.48 mL/min/{1.73_m2}` (`2017-01-01T23:50`) $\to$ range `5.49–124.48` $\to$ **latest `47.95 mL/min/{1.73_m2}` (`2026-08-16T23:50`)** [decreasing / trending down] [51]
- **Creatinine [Mass/volume] in Serum or Plasma** (114 measurements): initial `1.57 mg/dL` (`2017-01-01T23:50`) $\to$ range `1.47–2.99` $\to$ **latest `1.99 mg/dL` (`2026-08-16T23:50`)** [increasing / trending up] [53]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (100 measurements): initial `6.36 %` (`2017-01-01T23:50`) $\to$ range `2.81–6.36` $\to$ **latest `3.0 %` (`2026-08-16T23:50`)** [decreasing / trending down] [54]
- **Glucose [Mass/volume] in Serum or Plasma** (114 measurements): initial `97.02 mg/dL` (`2017-01-01T23:50`) $\to$ range `64.22–99.47` $\to$ **latest `67.68 mg/dL` (`2026-08-16T23:50`)** [decreasing / trending down] [55]
- **Potassium [Moles/volume] in Serum or Plasma** (114 measurements): initial `4.1 mmol/L` (`2017-01-01T23:50`) $\to$ range `3.71–5.19` $\to$ **latest `4.74 mmol/L` (`2026-08-16T23:50`)** [increasing / trending up] [56]
- **INR in Platelet poor plasma by Coagulation assay** (15 measurements): initial `1.12 {INR}` (`2023-10-08T06:40`) $\to$ range `0.82–2.04` $\to$ **latest `0.94 {INR}` (`2023-11-27T11:43`)** [decreasing / trending down] [140]
- **Hemoglobin [Mass/volume] in Blood** (17 measurements): initial `14.47 g/dL` (`2018-04-29T23:50`) $\to$ range `11.24–16.73` $\to$ **latest `11.63 g/dL` (`2023-11-27T11:43`)** [decreasing / trending down] [59] [60]

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [10] Condition (5693c080-f485-91e7-02ce-a7601c6d6df7): Condition: Has a criminal record (finding) (status: active, onset: 2015-04-13, SNOMED: 266948004)
• [11] Condition (5693c080-f485-91e7-4275-9febd44b35ce): Condition: Chronic kidney disease stage 1 (disorder) (status: active, onset: 2017-01-01, SNOMED: 431855005)
• [13] Condition (5693c080-f485-91e7-3c20-2954e787b490): Condition: Chronic kidney disease stage 2 (disorder) (status: active, onset: 2017-09-03, SNOMED: 431856006)
• [15] Condition (5693c080-f485-91e7-ac23-3ecc7b03578d): Condition: Chronic kidney disease stage 3 (disorder) (status: active, onset: 2018-09-30, SNOMED: 433144002)
• [51] Observation (5693c080-f485-91e7-0b17-9dbdd024f14d): Finding — Glomerular filtration rate (eGFR): 47.95 mL/min/{1.73_m2} (initial 124.48 on 2017-01-01 -> latest 47.95 on 2026-08-16; range 5.49 to 124.48 mL/min/{1.73_m2} over n=114 measurements, first recorded 2017-01-01 through 2026-08-16, trend: down)

### Active Medications & Reconciliation
- **Clopidogrel 75 MG Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: P2Y12 antiplatelet ('blood thinner') medication that prevents blood clots after coronary artery bypass grafting (CABG), stenting, or in ischemic heart disease.)* [24]
- **Simvastatin 20 MG Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: HMG-CoA reductase inhibitor (statin) used to lower LDL ('bad') cholesterol and reduce cardiovascular risk in ischemic heart disease.)* [25]
- **24 HR metoprolol succinate 100 MG Extended Release Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: Extended-release cardioselective beta-blocker used to treat ischemic heart disease, control blood pressure, and reduce heart workload after CABG surgery.)* [26]
- **Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: Fast-acting sublingual vasodilator spray used as needed to relieve or prevent acute chest pain (angina) in ischemic heart disease.)* [27]
- **insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin]** (started `2026-08-16`, source: `ACADEMY MANOR`) *(Purpose: Premixed intermediate- and short-acting human insulin injection used to control blood sugar in diabetes mellitus.)* [28]
- **Hydrochlorothiazide 25 MG Oral Tablet** (started `2026-08-16`, source: `ACADEMY MANOR`) *(Purpose: Thiazide diuretic ('water pill') prescribed to lower high blood pressure (essential hypertension) and reduce fluid retention.)* [29]

### High-Acuity Inpatient / Procedural Summary (2023-11-20 through 2023-11-28): Insertion of catheter into artery (procedure)
Maurice742 Marcos263 Auer97 was evaluated during 2023-11-20 through 2023-11-28 (Hospital admission (procedure)) with documented diagnoses including History of coronary artery bypass grafting (situation). Key procedures and interventions performed during this episode: Insertion of catheter into artery (procedure), Administration of anesthesia for procedure (procedure), Intubation (procedure), Pulmonary catheterization with Swan-Ganz catheter (procedure), Preparation of patient for procedure (regime/therapy). Documented implantable or patient-carried devices on chart: Blood glucose meter (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Operating room (environment). Episode and discharge medications recorded in window: cefazolin 2000 MG Injection, 1 ML heparin sodium, porcine 5000 UNT/ML Injection, 25 ML protamine sulfate (USP) 10 MG/ML Injection. [21] [30] [31] [32] [33] [81] [21] [91] [92] [93] [94] [95] [98]

- **Key Procedures:** Insertion of catheter into artery (procedure), Administration of anesthesia for procedure (procedure), Intubation (procedure), Pulmonary catheterization with Swan-Ganz catheter (procedure), Preparation of patient for procedure (regime/therapy), Cannulation (procedure), Cardiopulmonary bypass operation (procedure), Placement of aortic cross clamp (procedure)
- **Perioperative / Episode Medications:** cefazolin 2000 MG Injection (2023-11-20), cefazolin 2000 MG Injection (2023-11-20), 1 ML heparin sodium, porcine 5000 UNT/ML Injection (2023-11-20), 1 ML heparin sodium, porcine 5000 UNT/ML Injection (2023-11-20), 25 ML protamine sulfate (USP) 10 MG/ML Injection (2023-11-20), 25 ML protamine sulfate (USP) 10 MG/ML Injection (2023-11-20), 2 ML Ondansetron 2 MG/ML Injection (2023-11-20), 2 ML Ondansetron 2 MG/ML Injection (2023-11-20)
- **Implantable / Patient Devices:** Blood glucose meter (physical object), Dental x-ray system (physical object), Home-use sleep apnea recording system (physical object), Appliance for sleep apnea (physical object), Operating room (environment)

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [21] Condition (5693c080-f485-91e7-f448-62985ae4c285): Condition: History of coronary artery bypass grafting (situation) (status: active, onset: 2023-11-20, SNOMED: 399261000)
• [24] MedicationRequest (5693c080-f485-91e7-049d-0016c58b2394): Medication: Clopidogrel 75 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 309362)
• [25] MedicationRequest (5693c080-f485-91e7-aca9-a1fd06a66487): Medication: Simvastatin 20 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 312961)
• [26] MedicationRequest (5693c080-f485-91e7-26b2-d89012f695ca): Medication: 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 866412)
• [27] MedicationRequest (5693c080-f485-91e7-891c-b5a2d2f97b7a): Medication: Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 705129)
• [28] MedicationRequest (5693c080-f485-91e7-c785-40c0023e806d): Medication: insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin] (status: active, type: prescribed, reason: Prediabetes (finding), source: ACADEMY MANOR, RxNorm: 106892)

### Grounded Patient Health Summary: Maurice742 Marcos263 Auer97 (Patient Self-Access Full Health Summary)
- **Demographics & Anchor Date:** Birth date `1973-03-25`, reference date `2026-08-17` [1] [3] [4] [5] [6]
- **Active Problem List (21):** Educated to high school level (finding), Prediabetes (finding), Body mass index 30+ - obesity (finding), Anemia (disorder), Impacted molars (disorder), Essential hypertension (disorder), Metabolic syndrome X (disorder), Has a criminal record (finding), Chronic kidney disease stage 1 (disorder), Disorder of kidney due to diabetes mellitus (disorder), Chronic kidney disease stage 2 (disorder), Microalbuminuria due to type 2 diabetes mellitus (disorder), Chronic kidney disease stage 3 (disorder), Proteinuria due to type 2 diabetes mellitus (disorder), Sleep disorder (disorder), Sleep apnea (disorder), Ischemic heart disease (disorder), Abnormal findings diagnostic imaging heart+coronary circulat (finding), History of coronary artery bypass grafting (situation), Gingivitis (disorder), Part-time employment (finding)
- **Active Medications (6):** Clopidogrel 75 MG Oral Tablet, Simvastatin 20 MG Oral Tablet, 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet, Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray, insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin], Hydrochlorothiazide 25 MG Oral Tablet [24]
- **Data Quality Alerts Flagged:** `4` clinical reconciliation findings (2 high-severity)
- **Longitudinal Trajectories:** Glomerular filtration rate [Volume Rate/Area] in Serum or Plasma by Creatinine-based formula (MDRD)/1.73 sq M: 47.95 mL/min/{1.73_m2}, Creatinine [Mass/volume] in Serum or Plasma: 1.99 mg/dL, Hemoglobin A1c/Hemoglobin.total in Blood: 3.0 %, Glucose [Mass/volume] in Serum or Plasma: 67.68 mg/dL, Potassium [Moles/volume] in Serum or Plasma: 4.74 mmol/L

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [1] Patient (5693c080-f485-91e7-54b9-ad9a8c12af62): Patient: Maurice742 Marcos263 Auer97, DOB: 1973-03-25, Gender: male, Age: 53y (as of 2026-08-17), Language: English (United States)
• [3] Condition (5693c080-f485-91e7-32a9-b5480ad5e937): Condition: Educated to high school level (finding) (status: active, onset: 1991-05-20, SNOMED: 473461003)
• [4] Condition (5693c080-f485-91e7-387e-f0f4ab249a73): Condition: Prediabetes (finding) (status: active, onset: 1995-05-28, SNOMED: 714628002)
• [5] Condition (5693c080-f485-91e7-38d9-63f819020943): Condition: Body mass index 30+ - obesity (finding) (status: active, onset: 1995-05-28, SNOMED: 162864005)
• [6] Condition (5693c080-f485-91e7-a121-1912e8e4f3f1): Condition: Anemia (disorder) (status: active, onset: 1998-05-31, SNOMED: 271737000)

### Active Medications & Reconciliation
- **Clopidogrel 75 MG Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: P2Y12 antiplatelet ('blood thinner') medication that prevents blood clots after coronary artery bypass grafting (CABG), stenting, or in ischemic heart disease.)* — **ALERT: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel])** [24] [30]
- **Simvastatin 20 MG Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: HMG-CoA reductase inhibitor (statin) used to lower LDL ('bad') cholesterol and reduce cardiovascular risk in ischemic heart disease.)* — **ALERT: duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin])** [25]
- **24 HR metoprolol succinate 100 MG Extended Release Oral Tablet** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: Extended-release cardioselective beta-blocker used to treat ischemic heart disease, control blood pressure, and reduce heart workload after CABG surgery.)* [26]
- **Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray** (started `2023-09-06`, source: `LAWRENCE GENERAL HOSPITAL`) *(Purpose: Fast-acting sublingual vasodilator spray used as needed to relieve or prevent acute chest pain (angina) in ischemic heart disease.)* [27]
- **insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin]** (started `2026-08-16`, source: `ACADEMY MANOR`) *(Purpose: Premixed intermediate- and short-acting human insulin injection used to control blood sugar in diabetes mellitus.)* [28]
- **Hydrochlorothiazide 25 MG Oral Tablet** (started `2026-08-16`, source: `ACADEMY MANOR`) *(Purpose: Thiazide diuretic ('water pill') prescribed to lower high blood pressure (essential hypertension) and reduce fluid retention.)* [29]
- **Plavix 75 MG Oral Tablet [clopidogrel]** (started `2026-06-07`, source: `MultiCare Pulse Heart Institute`) *(Purpose: Brand-name clopidogrel antiplatelet ('blood thinner') medication used to prevent blood clots in coronary artery disease and after heart surgery.)* — **ALERT: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel])** [30]
- **Lipitor 40 MG Oral Tablet [atorvastatin]** (started `2026-06-07`, source: `MultiCare Pulse Heart Institute`) *(Purpose: High-intensity HMG-CoA reductase inhibitor (statin) prescribed to lower LDL cholesterol and protect coronary bypass grafts.)* — **ALERT: duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin])** [31]

### Duplicate Labs & Record Condensation Analysis (Tier 2: 4,066 tokens)
- **129 Duplicate Base64 Notes Eliminated:** Synthea / EHR export duplicated clinical encounter narratives across DocumentReference and DiagnosticReport.presentedForm[], plus repeated boilerplate problem/medication lists. SHA-256 payload hashing eliminated 129 exact duplicate note attachments while preserving 129 unique clinical narratives. 
- **2697 Raw Lab Measurements Consolidated Across 58 Canonical Analytes:** Identified 12 metabolic analytes split across parallel Blood vs. Serum/Plasma LOINC codes (Glucose, Urea nitrogen, Creatinine, Calcium, Sodium) and 8 analytes with same-day duplicate draws. Unified into canonical LOINC trajectories with initial, min/max, and latest values. [57] [60] [54] [55]
- **223 Historical Prescription Renewals Folded into 14 Ingredient Spans:** Condensed 223 stopped/completed MedicationRequest renewal entries into 14 canonical RxNorm ingredient intervals while preserving first-recorded and last-stopped dates and 100% of member FHIR resource UUIDs. 
- **750 Non-Clinical / Lookup Resources Stripped at Tier 0:** Removed 750 billing/administrative resources (Claim: 347, Device(clinic_equipment_retained): 6, ExplanationOfBenefit: 347, Medication: 11, Provenance: 1, SupplyDelivery: 38) after inverting Provenance.target[] and Organization/Practitioner references onto clinical resources. 

Clinician Technical Note: Rule wahs-kb-ckd-staging-01 (KDIGO 2024): Mutually exclusive active SNOMED CT CKD stages (Chronic kidney disease stage 1 (disorder) [431855005], Chronic kidney disease stage 2 (disorder) [431856006], Chronic kidney disease stage 3 (disorder) [433144002]). Reconcile against persistent 90-day eGFR (LOINC 33914-3 / 48642-3). Latest eGFR is 48.0 mL/min/{1.73_m2} on 2026-08-16T23:50 (historical nadir 5.5 on 2023-11-21T19:06). | Rule wahs-kb-glycemic-exclusivity-01 (ADA Standards of Care): SNOMED 44054006 (Diabetes mellitus type 2) supersedes SNOMED 714628002 (Prediabetes). Latest HbA1c is 3.0% on 2026-08-16T23:50. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (Clopidogrel 75 MG Oral Tablet [RxNorm 309362], Plavix 75 MG Oral Tablet [clopidogrel] [RxNorm 213169]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'clopidogrel' (Clopidogrel 75 MG Oral Tablet, Plavix 75 MG Oral Tablet [clopidogrel]). | Rule wahs-kb-rx-duplicate-statin-01: Active MedicationRequest conflict (Simvastatin 20 MG Oral Tablet [RxNorm 312961], Lipitor 40 MG Oral Tablet [atorvastatin] [RxNorm 617311]) across LAWRENCE GENERAL HOSPITAL, MultiCare Pulse Heart Institute. duplicate_therapy: concurrent ACTIVE statin prescriptions (Simvastatin 20 MG Oral Tablet, Lipitor 40 MG Oral Tablet [atorvastatin]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2024-04-28). acip_schedule_note: 2 doses of live zoster vaccine recorded (2023-05-28, 2024-04-28); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2025-09-28, CVX 140 on 2025-09-30). duplicate_candidate: Influenza recorded 2d apart (2025-09-28 vs 2025-09-30). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 32 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [24] MedicationRequest (5693c080-f485-91e7-049d-0016c58b2394): Medication: Clopidogrel 75 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 309362)
• [25] MedicationRequest (5693c080-f485-91e7-aca9-a1fd06a66487): Medication: Simvastatin 20 MG Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 312961)
• [26] MedicationRequest (5693c080-f485-91e7-26b2-d89012f695ca): Medication: 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 866412)
• [27] MedicationRequest (5693c080-f485-91e7-891c-b5a2d2f97b7a): Medication: Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray (status: active, type: prescribed, source: LAWRENCE GENERAL HOSPITAL, RxNorm: 705129)
• [28] MedicationRequest (5693c080-f485-91e7-c785-40c0023e806d): Medication: insulin isophane, human 70 UNT/ML / insulin, regular, human 30 UNT/ML Injectable Suspension [Humulin] (status: active, type: prescribed, reason: Prediabetes (finding), source: ACADEMY MANOR, RxNorm: 106892)
• [29] MedicationRequest (5693c080-f485-91e7-6036-1d5f2bcbef75): Medication: Hydrochlorothiazide 25 MG Oral Tablet (status: active, type: prescribed, reason: Essential hypertension (disorder), source: ACADEMY MANOR, RxNorm: 310798)

### Immunization History & ACIP Schedule Audit (12 doses in view)
- `2017-03-07`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [78]
- `2018-02-27`: **Influenza, split virus, trivalent, PF** (source: `BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.`) [79]
- `2019-03-12`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [72]
- `2021-02-16`: **zoster vaccine, live** (source: `ENHANCED MEDICAL CARE, LLC`) [67]
- `2021-02-16`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [68]
- `2022-02-22`: **zoster vaccine, live** (source: `ENHANCED MEDICAL CARE, LLC`) — **[acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US)]** [63]
- `2022-02-22`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [64]
- `2022-02-22`: **Td (adult), 5 Lf tetanus toxoid, preservative free, adsorbed** (source: `ENHANCED MEDICAL CARE, LLC`) [65]
- `2023-02-28`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [60]
- `2024-03-05`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [59]
- `2025-03-11`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [55]
- `2026-03-17`: **Influenza, split virus, trivalent, PF** (source: `ENHANCED MEDICAL CARE, LLC`) [52]

Clinician Technical Note: Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [52] Immunization (4be6b5fb-2a19-943a-3c5f-5ed5848e62c0): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: ENHANCED MEDICAL CARE, LLC)
• [55] Immunization (4be6b5fb-2a19-943a-b97d-8573207e0487): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: ENHANCED MEDICAL CARE, LLC)
• [59] Immunization (4be6b5fb-2a19-943a-bbf5-c4bb20d5cb11): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: ENHANCED MEDICAL CARE, LLC)
• [60] Immunization (4be6b5fb-2a19-943a-22c9-dee039eeeb0d): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: ENHANCED MEDICAL CARE, LLC)
• [63] Immunization (4be6b5fb-2a19-943a-fa10-c5d0fe05e7f5): Immunization: zoster vaccine, live (status: completed, CVX: 121, source: ENHANCED MEDICAL CARE, LLC)
• [64] Immunization (4be6b5fb-2a19-943a-4769-e631f7d3ab47): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: ENHANCED MEDICAL CARE, LLC)

### Clinical Problem List & Data Quality Findings
- **Active vs. Resolved Status Conflict: Chronic sinusitis (disorder)** (Cross-Clinic Condition Status Conflict): Cross-organization records disagree on the clinical status of Chronic sinusitis (disorder): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. Conflict note: status_conflict: Chronic sinusitis (disorder) marked ACTIVE (onset 2008-02-29) but also recorded as RESOLVED on 2024-09-10. *Recommendation:* Verify whether the condition resolved following specialist treatment and update the primary care active problem list. [6] [60]
- **Duplicate Active Ingredient Prescriptions (lisinopril 10 MG Oral Tablet vs. Prinivil 10 MG Oral Tablet [lisinopril])** (Brand vs. Generic Duplicate Therapy): Detected overlapping or interacting active medication orders across sources (SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic): lisinopril 10 MG Oral Tablet (2026-03-17) [SeaMar Community Health Primary Care]; Prinivil 10 MG Oral Tablet [lisinopril] (2026-05-12) [UW Medicine Cardiology Clinic]. Flag: duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). *Recommendation:* Perform immediate medication reconciliation with the patient and prescribing clinics to prevent accidental double-dosing, electrolyte toxicity, or bleeding complications. [11] [12]
- **ACIP Immunization Schedule Anomaly: Zoster-Live Series (1 doses)** (CDC ACIP Schedule Anomaly): Zoster-Live immunization entries (2022-02-22 [ENHANCED MEDICAL CARE, LLC]): acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). *Recommendation:* Review immunization series against CDC ACIP age-at-initiation and product-specific dosing intervals. [65]
- **7 Sensitive SDOH / Behavioral Health Records (Visible in Patient Self-View)** (Privacy & Consent Segmentation (42 CFR Part 2 / WA MHMDA)): Chart contains 7 privacy-sensitive SDOH or behavioral health items (Drug Abuse Screening Test-10 [DAST-10], Limited social contact (finding), Victim of intimate partner abuse (finding)). In 'patient_self' mode, these items are surfaced with [SDOH/PRIVACY-SENSITIVE] tags and require explicit patient consent before external sharing. *Recommendation:* Maintain strict consent segmentation when exporting directed summaries to schools, employers, or external providers. [9] [10] [78] [79] [80] [81] [82] [83] [84] [85]

### Supporting Renal, Metabolic & Hematologic Lab Trajectories
- **Creatinine [Mass/volume] in Blood** (12 measurements): initial `1.03 mg/dL` (`2017-03-07T21:18`) $\to$ range `0.93–1.24` $\to$ **latest `0.93 mg/dL` (`2026-06-23T21:18`)** [decreasing / trending down] [29]
- **Hemoglobin A1c/Hemoglobin.total in Blood** (13 measurements): initial `6.03 %` (`2017-03-07T21:18`) $\to$ range `5.85–6.37` $\to$ **latest `6.17 %` (`2026-06-23T21:18`)** [stable / trending stable] [30]
- **Glucose [Mass/volume] in Blood** (12 measurements): initial `66.2 mg/dL` (`2017-03-07T21:18`) $\to$ range `66.2–99.99` $\to$ **latest `68.65 mg/dL` (`2026-06-23T21:18`)** [stable / trending stable] [31]
- **Potassium [Moles/volume] in Blood** (12 measurements): initial `4.78 mmol/L` (`2017-03-07T21:18`) $\to$ range `3.87–5.16` $\to$ **latest `5.11 mmol/L` (`2026-06-23T21:18`)** [increasing / trending up] [32]
- **Hemoglobin [Mass/volume] in Blood** (2 measurements): initial `13.24 g/dL` (`2017-03-07T21:18`) $\to$ range `13.24–16.26` $\to$ **latest `16.26 g/dL` (`2023-02-28T21:18`)** [increasing / trending up] [86]

Clinician Technical Note: Rule wahs-kb-active-vs-resolved-01: Cross-organization Condition.clinicalStatus discrepancy for Chronic sinusitis (disorder) (SNOMED 40055000): ACTIVE (2008-02-29) via BETH ISRAEL DEACONESS HOSPITAL-NEEDHAM, INC.; RESOLVED (2024-09-10) via Primary Clinic. | Rule wahs-kb-rx-brand-generic-01: Active MedicationRequest conflict (lisinopril 10 MG Oral Tablet [RxNorm 314076], Prinivil 10 MG Oral Tablet [lisinopril] [RxNorm 206765]) across SeaMar Community Health Primary Care, UW Medicine Cardiology Clinic. duplicate_therapy: multiple ACTIVE prescriptions for ingredient 'lisinopril' (lisinopril 10 MG Oral Tablet, Prinivil 10 MG Oral Tablet [lisinopril]). | Rule wahs-kb-acip-zoster-01 (CDC ACIP / WA IIS): Zoster-Live Immunization resources (CVX 121 on 2022-02-22). acip_schedule_note: 2 doses of live zoster vaccine recorded (2021-02-16, 2022-02-22); live zoster was a single-dose vaccine (superseded by 2-dose recombinant Shingrix in US). | Rule wahs-kb-sdoh-privacy-01 (42 CFR Part 2 / WA MHMDA): 7 SDOH/PRIVACY-SENSITIVE resources segmented by posture='patient_self' (redacted_for_privacy=0).

• [6] Condition (4be6b5fb-2a19-943a-19f7-35a11a488712): Condition: Chronic sinusitis (disorder) (status: active, onset: 2008-02-29, SNOMED: 40055000)
• [9] Condition (4be6b5fb-2a19-943a-7617-5e43e4960522): Condition: Victim of intimate partner abuse (finding) (status: active, onset: 2026-03-17, SNOMED: 706893006)
• [10] Condition (4be6b5fb-2a19-943a-09e1-bbaa61fbdd16): Condition: Limited social contact (finding) (status: active, onset: 2026-06-23, SNOMED: 423315002)
• [11] MedicationRequest (med-pcp-lamar-lisinopril): Medication: lisinopril 10 MG Oral Tablet (status: active, type: prescribed, source: SeaMar Community Health Primary Care, RxNorm: 314076)
• [12] MedicationRequest (med-cardio-lamar-prinivil): Medication: Prinivil 10 MG Oral Tablet [lisinopril] (status: active, type: prescribed, source: UW Medicine Cardiology Clinic, RxNorm: 206765)
• [29] Observation (4be6b5fb-2a19-943a-bd5f-647eb1eec07d): Finding — Creatinine [Mass/volume] in Blood: 0.93 mg/dL (initial 1.03 on 2017-03-07 -> latest 0.93 on 2026-06-23; range 0.93 to 1.24 mg/dL over n=12 measurements, first recorded 2017-03-07 through 2026-06-23, trend: down)

### Immunization History & ACIP Schedule Audit (18 doses in view)
- `2016-12-05`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [74]
- `2017-12-11`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [75]
- `2018-12-17`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [76]
- `2019-12-23`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [77]
- `2020-12-28`: **Tdap** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [78] [80]
- `2020-12-28`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [79]
- `2020-12-28`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [80]
- `2020-12-28`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [81]
- `2021-12-27`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) [68]
- `2022-01-03`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [65]
- `2022-01-03`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [66]
- `2022-01-17`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) [64]
- `2022-05-02`: **HPV, quadrivalent** (source: `LAWRENCE GENERAL HOSPITAL`) — **[acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15]** [56]
- `2023-01-09`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [53]
- `2024-01-15`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [43]
- `2025-01-20`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [39]
- `2026-01-26`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [26]
- `2026-01-26`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [27]

Clinician Technical Note: Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15.

• [26] Immunization (83093df7-a1e4-b827-159b-4271c06f5179): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [27] Immunization (83093df7-a1e4-b827-b763-089cd8c363c6): Immunization: meningococcal MCV4P (status: completed, CVX: 114, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [39] Immunization (83093df7-a1e4-b827-6ea6-0974e08a5de5): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [43] Immunization (83093df7-a1e4-b827-495f-09836498a3cb): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [53] Immunization (83093df7-a1e4-b827-b62b-2cd322ef34df): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [56] Immunization (83093df7-a1e4-b827-9ba3-181c9443b46b): Immunization: HPV, quadrivalent (status: completed, CVX: 62, source: LAWRENCE GENERAL HOSPITAL)

### Immunization History & ACIP Schedule Audit (20 doses in view)
- `2016-12-05`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [73]
- `2017-12-11`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [74]
- `2018-12-17`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [75]
- `2019-12-23`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [76]
- `2020-12-28`: **Tdap** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [77]
- `2020-12-28`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [78]
- `2020-12-28`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [79]
- `2020-12-28`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [80]
- `2021-12-27`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) [81]
- `2022-01-03`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [66]
- `2022-01-03`: **HPV, quadrivalent** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [82]
- `2022-01-17`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `LAWRENCE GENERAL HOSPITAL`) — **[duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18)]** [65]
- `2022-05-02`: **HPV, quadrivalent** (source: `LAWRENCE GENERAL HOSPITAL`) — **[acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15]** [56]
- `2023-01-09`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [53]
- `2024-01-15`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [43]
- `2025-01-20`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [39]
- `2026-01-26`: **Influenza, split virus, trivalent, PF** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) — **[duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28)]** [26]
- `2026-01-26`: **meningococcal MCV4P** (source: `NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC`) [27]
- `2026-01-28`: **Influenza, split virus, trivalent, PF** (source: `WA State IIS Immunization Registry (Pharmacy Feed)`) — **[duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28)]** [15]
- `2022-01-18`: **COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose** (source: `Bartell Drugs #42 - Seattle`) — **[duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18)]** [60]

Clinician Technical Note: Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): COVID-19 Immunization resources (CVX 208 on 2022-01-17, CVX 208 on 2022-01-18). duplicate_candidate: COVID-19 recorded 1d apart (2022-01-17 vs 2022-01-18). | Rule wahs-kb-acip-hpv-01 (CDC ACIP / WA IIS): HPV Immunization resources (CVX 62 on 2022-05-02). acip_schedule_note: 3rd HPV dose recorded after series initiated at age 11 (2020-12-28); CDC ACIP specifies 2-dose series when started before age 15. | Rule wahs-kb-iis-dedup-01 (CDC ACIP / WA IIS): Influenza Immunization resources (CVX 140 on 2026-01-26, CVX 140 on 2026-01-28). duplicate_candidate: Influenza recorded 2d apart (2026-01-26 vs 2026-01-28).

• [15] Immunization (imm-iis-byron-flu-2026): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: WA State IIS Immunization Registry (Pharmacy Feed))
• [26] Immunization (83093df7-a1e4-b827-159b-4271c06f5179): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [27] Immunization (83093df7-a1e4-b827-b763-089cd8c363c6): Immunization: meningococcal MCV4P (status: completed, CVX: 114, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [39] Immunization (83093df7-a1e4-b827-6ea6-0974e08a5de5): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [43] Immunization (83093df7-a1e4-b827-495f-09836498a3cb): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)
• [53] Immunization (83093df7-a1e4-b827-b62b-2cd322ef34df): Immunization: Influenza, split virus, trivalent, PF (status: completed, CVX: 140, source: NEW ENGLAND PROFESSIONAL HOME HEALTH CARE LLC)

**Not Recorded in Chart (Grounded Abstention):** I reviewed Maurice742 Marcos263 Auer97's condensed health record [1] (covering 7,096 FHIR Bundle entries through `2026-08-17`) and found **no documentation of genetic or pharmacogenomic testing (e.g., APOE4, CYP2C19, BRCA)**.

- **Allergy & Clinical Core Check:** Structured `AllergyIntolerance`, `Procedure`, `DiagnosticReport`, and `Observation` resources contain no matching records for this request.
- **Safety Posture:** Per WAHS clinical grounding rules, the assistant abstains rather than inferring or fabricating unrecorded clinical history.

Clinician Technical Note: Deterministic abstention (Use Case B-3): Zero matching AllergyIntolerance, Procedure, DiagnosticReport, or Observation resources for 'genetic or pharmacogenomic testing (e.g., APOE4, CYP2C19, BRCA)' across 7,096 bundle entries [1].

• [1] Patient (5693c080-f485-91e7-54b9-ad9a8c12af62): Patient: Maurice742 Marcos263 Auer97, DOB: 1973-03-25, Gender: male, Age: 53y (as of 2026-08-17), Language: English (United States)

**Not Recorded in Chart (Grounded Abstention):** I reviewed Maurice742 Marcos263 Auer97's condensed health record [1] (covering 7,096 FHIR Bundle entries through `2026-08-17`) and found **no documentation of a documented drug/food anaphylactic allergy, peanut-specific IgE, or epinephrine auto-injector**.

- **Allergy & Clinical Core Check:** Structured `AllergyIntolerance`, `Procedure`, `DiagnosticReport`, and `Observation` resources contain no matching records for this request.
- **Safety Posture:** Per WAHS clinical grounding rules, the assistant abstains rather than inferring or fabricating unrecorded clinical history.

Clinician Technical Note: Deterministic abstention (Use Case B-3): Zero matching AllergyIntolerance, Procedure, DiagnosticReport, or Observation resources for 'a documented drug/food anaphylactic allergy, peanut-specific IgE, or epinephrine auto-injector' across 7,096 bundle entries [1].

• [1] Patient (5693c080-f485-91e7-54b9-ad9a8c12af62): Patient: Maurice742 Marcos263 Auer97, DOB: 1973-03-25, Gender: male, Age: 53y (as of 2026-08-17), Language: English (United States)

**Not Recorded in Chart (Grounded Abstention):** I reviewed Lamar193 Oswaldo857 Beer512's condensed health record [1] (covering 889 FHIR Bundle entries through `2026-07-08`) and found **no documentation of a quantitative left ventricular ejection fraction (LVEF %) measurement**.

- **Allergy & Clinical Core Check:** Structured `AllergyIntolerance`, `Procedure`, `DiagnosticReport`, and `Observation` resources contain no matching records for this request.
- **Safety Posture:** Per WAHS clinical grounding rules, the assistant abstains rather than inferring or fabricating unrecorded clinical history.

Clinician Technical Note: Deterministic abstention (Use Case B-3): Zero matching AllergyIntolerance, Procedure, DiagnosticReport, or Observation resources for 'a quantitative left ventricular ejection fraction (LVEF %) measurement' across 889 bundle entries [1].

• [1] Patient (4be6b5fb-2a19-943a-9249-7068445be4cc): Patient: Lamar193 Oswaldo857 Beer512, DOB: 1971-02-16, Gender: male, Age: 55y (as of 2026-07-08), Language: English (United States)

**Not Recorded in Chart (Grounded Abstention):** I reviewed Byron202 Carmen818 Emard19's condensed health record [1] (covering 478 FHIR Bundle entries through `2026-02-10`) and found **no documentation of a documented drug/food anaphylactic allergy, peanut-specific IgE, or epinephrine auto-injector**.

- **Allergy & Clinical Core Check:** Structured `AllergyIntolerance`, `Procedure`, `DiagnosticReport`, and `Observation` resources contain no matching records for this request.
- **Safety Posture:** Per WAHS clinical grounding rules, the assistant abstains rather than inferring or fabricating unrecorded clinical history.

Clinician Technical Note: Deterministic abstention (Use Case B-3): Zero matching AllergyIntolerance, Procedure, DiagnosticReport, or Observation resources for 'a documented drug/food anaphylactic allergy, peanut-specific IgE, or epinephrine auto-injector' across 478 bundle entries [1].

• [1] Patient (83093df7-a1e4-b827-72e6-c6d604fd7748): Patient: Byron202 Carmen818 Emard19, DOB: 2009-12-14, Gender: male, Age: 16y (as of 2026-02-10), Language: English (United States)