SYNTHETIC RECORD - Example Cedar Grove Rheumatology - Follow-up Visit - 2026-07-15
Patient reference SYN-6674.
Subjective: 29-year-old woman with seropositive rheumatoid arthritis, diagnosed in 2023, reports continued swelling in her hands and feet despite completing methotrexate.
Objective: CDAI calculated at 28, indicating high disease activity. Synovitis present at bilateral wrists and MTPs.
Assessment: Rheumatoid arthritis with inadequate response to oral methotrexate 2026-02-09 to 2026-07-06, discontinued for lack of improvement.
Plan: Initiate Immunara. Continue folic acid. Recheck labs in six weeks.
Lab report
lab_report
SYNTHETIC RECORD - Example Cedar Grove Rheumatology - Laboratory Report - 2026-07-10
Patient reference SYN-6674.
Rheumatoid factor: positive, 54 IU/mL (reference <14).
Anti-CCP antibody: positive, 71 U/mL (reference <20).
Complete blood count: within normal limits.
Liver function panel: within normal limits.
Medication history
medication_history
SYNTHETIC RECORD - Example Cedar Grove Rheumatology - Medication History - 2026-07-15
Patient reference SYN-6674.
METHOTREXATE 15 MG PO WEEKLY - status: inactive - start 2026-02-09 - end 2026-07-06 - reason: inadequate response (CDAI 28)
FOLIC ACID 1 MG PO DAILY - status: active
Decisions by provider
AUTO_PROCESS·correct
Decided by: auto_process gate · auto_process 0.89
Judgments
p_yes for yes/no questions; ticks are the thresholds a gate compares each one with.
Diagnosis supported
auto 0.89
0.980
Step therapy met
auto 0.89
0.980
Documentation complete
auto 0.89request info 0.60
0.980
Material contradiction
review 0.80block 0.20
0.050
Missing evidence
NONE 0.980
others: DOSAGE 0.02
Gate path· 7 gates, in engine order
providerpassed
all five decisions present and well-formed
agepassed
patient.age=29, policy min_age=18
contradictionpassed
p_yes(material_contradiction)=0.050, review at >= 0.8
documentationpassed
p_yes(documentation_complete)=0.980, request info below 0.6
missing_evidencepassed
missing_evidence=NONE (p=0.980), request info at >= 0.7
auto_processFIRED → AUTO_PROCESS
min(required p_yes)=0.980, auto at >= 0.89; p_yes(material_contradiction)=0.050, blocks at >= 0.2
default_reviewnot reached
passed = the gate checked and did not fire; not reached = an earlier gate decided.
all required judgments are at or above 0.89 and contradiction risk is below 0.2