# Held-out Case 01 — Okafor (SYNTHETIC) — Answer Key

Everything in this record is fictional. 1,000 pages, Bates OKAFOR-000001 to OKAFOR-001000. Built 2026-09-07 by a script (`build_case.py`), so every number below is exact by construction.

## The story in one paragraph

Daniel R. Okafor (fictional), DOB 03/14/1981, was the restrained driver of a stopped car rear-ended by a pickup on **02/11/2026**. ED the same day at St. Brendan's: cervical and lumbar strain, CT/XR negative for fracture. Five days later his PCP found new left-arm tingling and referred to orthopedics. MRI on 03/03/2026 showed a left C5–C6 disc protrusion with an annular fissure contacting the C6 root (radiologist: favors recent injury on mild degeneration). He did 30 physical-therapy visits (03/17–06/26), two cervical epidural injections (04/21 and 06/09), and had a two-day observation stay (04/28–04/30) after lifting a bag of mulch at home made the pain intolerable. Surgery (ACDF) was discussed and conditionally recommended but never needed. MMI on **08/25/2026** with no permanent restrictions. Pre-existing history: six chiropractic visits in fall 2023 for **low back** strain (resolved), and one 2022 mention of neck stiffness after long drives, untreated.

## The five numbers to record when RITA runs it

1. Wall-clock time for 1,000 pages, ingest → chronology → pod.
2. Distinct encounters found vs **56** expected (see list below; the flowsheet floods must not inflate this).
3. Traps caught, out of **18** (table below).
4. Questions answered correctly, out of **18**, with every fact cited to a Bates page.
5. Pod preflight: ok, zero PHI leaks (the wrong-patient page contains a second person's name/DOB/MRN — those must be scrubbed too).

## Traps (what a careless system gets wrong)

| # | Bates | Kind | What must happen |
|---|---|---|---|
| 1 | OKAFOR-000004 | pre_existing_subtle | 2022 annual exam mentions 'occasional neck stiffness after long drives' — a defense talking point; must be reported as documented and as untreated, not as a prior neck injury. |
| 2 | OKAFOR-000018 | undated_note | Telephone encounter has no date of service. Must be reported as undated (NA); must NOT inherit 02/16/2026 or 02/24/2026 from neighbors. Internal text mentions 02/17 as the referral fax date, which is not the encounter date. |
| 3 | OKAFOR-000021 | fax_banner_wrong_date | Every St. Brendan's page carries a fax banner dated Jun. 03 2026. Dates of service are 02/11/2026 and 04/28–04/30/2026. The fax date must never become an event date. |
| 4 | OKAFOR-000021 | letterhead_variants | St. Brendan's appears as full letterhead, as 'SBRMC – Emergency Department', and as a stamp 'ST BRENDANS REG MED CTR HIM ***COPY***'. All are one facility. |
| 5 | OKAFOR-000030 | epic_one_entry_per_page | ED flowsheets are printed one timestamp per page with a repeated header (40 near-identical pages). They are part of the single ED encounter; each page must not become an event. |
| 6 | OKAFOR-000070 | date_format_drift | This ED note prints dates as 2026-04-28 (ISO). Other St. Brendan's pages use 04/28/2026 and 'Apr 29, 2026'. All must parse to the same dates. |
| 7 | OKAFOR-000141 | flowsheet_type | 518 flowsheet pages within the observation stay; must be nursing documentation of ONE stay, not emergency_department, and not 518 events. |
| 8 | OKAFOR-000679 | multi_page_running_header | 4-page encounter with per-page running header; must be ONE event with page span of 4. |
| 9 | OKAFOR-000683 | out_of_order_pages | Pages of the 03/10/2026 note are in scan order 1,3,2,4 (running header shows the true page numbers). Must be one event; content must not be treated as two encounters. |
| 10 | OKAFOR-000689 | treatment_gap | No treatment between 07/07/2026 and 08/25/2026 (49 days). The note gives the reason (work travel). A gap question must report the dates on either side and the documented reason, not speculate. |
| 11 | OKAFOR-000715 | duplicate_page | Exact re-send of OKAFOR-000714 (PT visit 7 last page). Must not create a second visit or duplicate its content; flag as duplicate. |
| 12 | OKAFOR-000737 | wrong_patient_page | PT note for a DIFFERENT patient (Okafor-Reyes, Danielle M., DOB 07/22/1979, MRN CPT-558123, post-TKA) misfiled into this record. Must be flagged as wrong-patient and must NOT become an event for Mr. Okafor. A knee replacement must never appear in his chronology. |
| 13 | OKAFOR-000786 | duplicate_charge | PT ledger bills visit 7 (04/01/2026) twice: $300.00 duplicated. Printed total $9,645.00; correct total $9,345.00. |
| 14 | OKAFOR-000802 | same_date_two_facilities | 07/07/2026 has two encounters: Northgate Orthopedic and Summit Pain & Spine. Both must survive as separate events. |
| 15 | OKAFOR-000804 | pharmacy_not_visits | Pharmacy dispensing rows are fills, not encounters. Prior-year loratadine fills are unrelated to the injury. |
| 16 | OKAFOR-000810 | pre_existing_lumbar | Six 2023 chiropractic visits for LOW BACK pain after lifting at work, resolved and discharged 11/06/2023. This is the real pre-existing condition. It concerns the lumbar spine, not the cervical spine; it must be reported as documented, resolved, and pre-dating the collision by 27 months. |
| 17 | OKAFOR-000818 | billing_itemization_missing | Observation-stay statement shows 'Pharmacy — see itemization $0.00' and says itemization is available on request. The ledger is incomplete; a records request for the itemized bill is the correct action. |
| 18 | OKAFOR-000823 | bulk_flowsheets_out_of_sequence | 178 pages of nursing flowsheets produced at the end of the package (after the chiropractic section) belong to the 04/28–04/30/2026 observation stay. They must attach to that stay, not become a new episode dated by their position in the file. |

## Counts

- distinct_encounters: **56**
- pt_visits: **30**
- imaging_studies_performed: **5**
- esi_procedures: **2**
- hospital_stays: **1**
- pre_injury_encounters: **9**
- undated_encounters: **1**
- wrong_patient_pages: **1**
- duplicate_pages: **1**

## Imaging studies actually performed

- 02/11/2026 — CT cervical spine (OKAFOR-000024)
- 02/11/2026 — XR lumbar spine (OKAFOR-000025)
- 04/28/2026 — CT cervical spine (OKAFOR-000071)
- 03/03/2026 — MRI cervical spine (OKAFOR-000691)
- 03/03/2026 — MRI lumbar spine (OKAFOR-000692)

## Billing

- ED 02/11/2026: $5,229.00
- Observation 04/28-04/30/2026: $13,147.00
- Northgate: $1,560.00
- Bayview: $3,300.00
- Summit: $11,630.00
- HFM: $185.00
- Cascade PT (as printed): $9,645.00
- **Total post-injury as printed: $44,696.00**
- **Correct total after removing the duplicated PT visit-7 charges ($300.00): $44,396.00**
- Pre-injury chiropractic (2023), excluded from specials: $390.00
- Observation-stay pharmacy/supply itemization is missing ('available on request') — the records request RITA should generate.

## Key facts

- **mechanism**: Restrained driver, stopped at a traffic light, struck from behind by a pickup truck (~30–35 mph) on 02/11/2026.
- **primary_injury**: Left paracentral C5–C6 disc protrusion with annular fissure and left C6 radiculopathy (MRI 03/03/2026); cervical strain; lumbar strain with mild L4–L5 degenerative bulge.
- **surgery**: None performed. ACDF C5–C6 discussed 03/10/2026 and recommended conditionally 05/19/2026; deferred 07/07/2026; not needed at MMI 08/25/2026.
- **injections**: Two cervical interlaminar ESIs: 04/21/2026 and 06/09/2026 (Summit Pain & Spine, Dr. Demirci).
- **hospitalization**: Observation stay St. Brendan's 04/28/2026–04/30/2026 for acute exacerbation after lifting mulch at home (intervening event the defense will cite).
- **physical_therapy**: 30 visits, Cascade Physical Therapy, 03/17/2026–06/26/2026, Jonah P. Whitfield PT DPT; NDI 44% → 14%.
- **pre_existing**: (1) Six chiropractic visits 09/18/2023–11/06/2023 for LUMBAR strain after lifting at work, resolved. (2) 03/10/2022 PCP note: occasional neck stiffness after long drives, untreated. (3) CT 02/11/2026 and MRI 03/03/2026 note mild C5–C6 degenerative change; radiologist states annular fissure/STIR favor recent injury superimposed on degeneration. No prior neck treatment anywhere in the record.
- **mmi**: 08/25/2026, Dr. Adebayo; no permanent restrictions; risk of recurrence noted.
- **work_restrictions**: 02/16/2026: no lifting >15 lb x2 weeks. 02/24/2026: no lifting >15 lb, no overhead. 05/19/2026: no lifting >20 lb, no overhead. 07/07/2026: 30 lb, overhead in 15-min intervals. 08/25/2026: none.
- **treatment_gap**: 07/07/2026 → 08/25/2026 (49 days), documented reason: work travel.
- **intervening_event**: 04/27/2026 lifting a 40-lb bag of mulch at home precipitated the exacerbation leading to the observation stay.
- **same_day_two_facilities**: 07/07/2026: Northgate Orthopedic AND Summit Pain & Spine.
- **wrong_patient**: name: Okafor-Reyes, Danielle M., dob: 07/22/1979, mrn: CPT-558123

## Distinct encounters expected (56)

| Dates | Facility | First Bates |
|---|---|---|
| 03/10/2022 | Harbor Family Medicine | OKAFOR-000004 |
| 04/02/2024 | Harbor Family Medicine | OKAFOR-000005 |
| 05/20/2025 | Harbor Family Medicine | OKAFOR-000006 |
| 02/16/2026 | Harbor Family Medicine | OKAFOR-000017 |
| NA (undated) | Harbor Family Medicine | OKAFOR-000018 |
| 02/11/2026 | St. Brendan's Regional Medical Center | OKAFOR-000021 |
| 02/11/2026 | St. Brendan's Regional Medical Center | OKAFOR-000024 |
| 04/28/2026, 04/29/2026, 04/30/2026 | St. Brendan's Regional Medical Center | OKAFOR-000070 |
| 04/28/2026 | St. Brendan's Regional Medical Center | OKAFOR-000071 |
| 02/24/2026 | Northgate Orthopedic Associates | OKAFOR-000679 |
| 03/10/2026 | Northgate Orthopedic Associates | OKAFOR-000683 |
| 05/19/2026 | Northgate Orthopedic Associates | OKAFOR-000687 |
| 07/07/2026 | Northgate Orthopedic Associates | OKAFOR-000688 |
| 08/25/2026 | Northgate Orthopedic Associates | OKAFOR-000689 |
| 03/03/2026 | Bayview Imaging Center | OKAFOR-000691 |
| 03/18/2026 | Cascade Physical Therapy | OKAFOR-000694 |
| 03/20/2026 | Cascade Physical Therapy | OKAFOR-000697 |
| 03/23/2026 | Cascade Physical Therapy | OKAFOR-000700 |
| 03/25/2026 | Cascade Physical Therapy | OKAFOR-000703 |
| 03/27/2026 | Cascade Physical Therapy | OKAFOR-000706 |
| 03/30/2026 | Cascade Physical Therapy | OKAFOR-000709 |
| 04/01/2026 | Cascade Physical Therapy | OKAFOR-000712 |
| 04/03/2026 | Cascade Physical Therapy | OKAFOR-000716 |
| 04/06/2026 | Cascade Physical Therapy | OKAFOR-000719 |
| 04/08/2026 | Cascade Physical Therapy | OKAFOR-000722 |
| 04/10/2026 | Cascade Physical Therapy | OKAFOR-000725 |
| 04/13/2026 | Cascade Physical Therapy | OKAFOR-000728 |
| 04/15/2026 | Cascade Physical Therapy | OKAFOR-000731 |
| 04/17/2026 | Cascade Physical Therapy | OKAFOR-000734 |
| 04/20/2026 | Cascade Physical Therapy | OKAFOR-000738 |
| 04/22/2026 | Cascade Physical Therapy | OKAFOR-000741 |
| 04/24/2026 | Cascade Physical Therapy | OKAFOR-000744 |
| 04/27/2026 | Cascade Physical Therapy | OKAFOR-000747 |
| 05/04/2026 | Cascade Physical Therapy | OKAFOR-000750 |
| 05/06/2026 | Cascade Physical Therapy | OKAFOR-000753 |
| 05/08/2026 | Cascade Physical Therapy | OKAFOR-000756 |
| 05/11/2026 | Cascade Physical Therapy | OKAFOR-000759 |
| 05/13/2026 | Cascade Physical Therapy | OKAFOR-000762 |
| 05/15/2026 | Cascade Physical Therapy | OKAFOR-000765 |
| 05/18/2026 | Cascade Physical Therapy | OKAFOR-000768 |
| 05/20/2026 | Cascade Physical Therapy | OKAFOR-000771 |
| 05/22/2026 | Cascade Physical Therapy | OKAFOR-000774 |
| 05/25/2026 | Cascade Physical Therapy | OKAFOR-000777 |
| 05/27/2026 | Cascade Physical Therapy | OKAFOR-000780 |
| 05/29/2026 | Cascade Physical Therapy | OKAFOR-000783 |
| 04/07/2026 | Summit Pain & Spine | OKAFOR-000790 |
| 04/21/2026 | Summit Pain & Spine | OKAFOR-000791 |
| 05/12/2026 | Summit Pain & Spine | OKAFOR-000796 |
| 06/09/2026 | Summit Pain & Spine | OKAFOR-000797 |
| 07/07/2026 | Summit Pain & Spine | OKAFOR-000802 |
| 09/18/2023 | Oak Street Chiropractic | OKAFOR-000810 |
| 09/25/2023 | Oak Street Chiropractic | OKAFOR-000811 |
| 10/02/2023 | Oak Street Chiropractic | OKAFOR-000812 |
| 10/16/2023 | Oak Street Chiropractic | OKAFOR-000813 |
| 10/30/2023 | Oak Street Chiropractic | OKAFOR-000814 |
| 11/06/2023 | Oak Street Chiropractic | OKAFOR-000815 |

## Question battery (ask RITA; expected answer)

**1. Give me a case summary.**  
Rear-end MVC 02/11/2026; ED same day; C5–C6 protrusion with L C6 radiculopathy on MRI 03/03/2026; 30 PT visits; 2 ESIs; observation stay 04/28–04/30 after lifting mulch; MMI 08/25/2026; no surgery. Every fact cited to a Bates page.

**2. Does the record show any pre-existing condition?**  
Yes: 2023 chiropractic care for LOW BACK strain (6 visits, resolved), and a 2022 mention of occasional neck stiffness, untreated. Must distinguish lumbar history from the cervical injury and cite the radiologist's 'recent injury superimposed on mild degeneration' language.

**3. List every imaging study with its date and result.**  
CT c-spine 02/11/2026; XR lumbar 02/11/2026; MRI c-spine 03/03/2026; MRI l-spine 03/03/2026; CT c-spine 04/28/2026. Five performed studies; an MRI 'reviewed' on 03/10 is not a sixth.

**4. Did the patient have surgery?**  
No. ACDF discussed and conditionally recommended; deferred; not needed at MMI.

**5. How many epidural injections did he receive, and when?**  
Two: 04/21/2026 and 06/09/2026.

**6. Was he ever admitted to the hospital?**  
Observation stay 04/28–04/30/2026 at St. Brendan's, precipitated by lifting a bag of mulch. Must state the intervening event.

**7. How many physical therapy visits, over what dates, and with whom?**  
30 visits, 03/18/2026–05/29/2026, Jonah P. Whitfield PT DPT (initial evaluation 03/18; re-evaluations at visits 10, 20, 30; discharge 05/29). Not 31 (duplicate page 000715) and not counting the wrong-patient note (000737).

**8. Is there any page in this record that does not belong to this patient?**  
Yes: a PT note for Okafor-Reyes, Danielle M. (DOB 07/22/1979, MRN CPT-558123, post-knee-replacement) at the Bates number in the key.

**9. What happened on 05/25/2026?**  
PT visit 28 of 30 at Cascade Physical Therapy (Jonah P. Whitfield PT DPT), Bates 000777–000779. Nothing else that day.

**10. Did the patient ever have a knee replacement?**  
No. The only knee-replacement text is on the wrong-patient page and must not be attributed to Mr. Okafor.

**11. Are there gaps in treatment?**  
07/07/2026 to 08/25/2026, 49 days, documented reason at the 08/25 MMI visit: patient traveling. (PT paused 04/28–05/01 for the hospital stay is not a gap in care.)

**12. What are his current work restrictions?**  
None as of 08/25/2026 (MMI). Give the progression with dates.

**13. What is the total billed for injury-related care?**  
As printed $44,696.00; correct $44,396.00 after removing the duplicated PT visit-7 charges ($300.00). Observation pharmacy itemization is missing and must be flagged. Chiropractic $390 (2023) is pre-injury and excluded.

**14. Are there any duplicate charges?**  
Yes: Cascade PT ledger bills visit 7 twice.

**15. What date did the fax from St. Brendan's arrive, and is that a date of service?**  
Fax banner Jun. 03 2026 on every St. Brendan's page; it is NOT a date of service and must not appear as an event.

**16. Who was the treating orthopedic surgeon and what did he recommend on 05/19/2026?**  
Rowan K. Adebayo, MD; ACDF C5–C6 if radicular symptoms persist 3 months after the second ESI.

**17. Describe what happened on 07/07/2026.**  
Two visits at two facilities: Northgate ortho (improving, surgery deferred, 30-lb limit) and Summit Pain (70% relief, no further injections).

**18. Which page is the 03/10/2026 orthopedic note on, and is it complete?**  
Four pages, produced in order 1,3,2,4 per the running header; one encounter.


## Errata
- 2026-09-10: Q7, Q9, Q11 expected text corrected to match the encounter list (exact by construction). RITA's run05 answers to Q7 and Q9 were correct against the built record.