IV furosemide 40mg q12h started this admission for fluid overload secondary to CHF exacerbation. IV vancomycin 1g q12h also initiated for UTI with suspected urosepsis. Peripheral IV site to right forearm patent, no signs of infiltration. Patient tolerating IV medication well. Strict I&Os monitored.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-04
I0900Peripheral Vascular Disease···☐ NOT CODED
I2000Pneumonia···☐ NOT CODED
I2500Wound Infection···☐ NOT CODED
I3500Pressure Ulcer Stage 3···☐ NOT CODED
I4500Diabetes Mellitus···☐ NOT CODED
MDS · Section O — Special Treatments · target 2026-04-04
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···☐ NOT CODED
Gap detection · grounded
claude-opus-4-7 · 847ms · 2.1k tok
DEPRESSIONmedium
Notes describe depressive symptoms. Score a PHQ-9 (D0150) or staff assessment (D0500) at next MDS to capture for nursing classification.
Field: pdpmDepression
Evidence: "[MSW] ... soon as she is able. Resident appeared tearful at times when discussing her prognosis and independence. Psychosocial concerns ...", "[MD] ...ay 5. Patient reports poor appetite and low mood, stating she feels 'like a burden' and is worried about her future functional s..."
IV MEDICATIONSmedium
Notes describe IV medications. Verify and check the IV-medications box (O0100H) if administered in last 14 days.
Field: O0100H
Evidence: "[RN] ...gns of infiltration. Patient tolerating IV medication well. Strict I&Os monitored...."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...gns post-fall: BP 136/82, HR 88, RR 17, SpO2 96% RA. Right hip surgical site inspected — no new deformity, erythema, or drai...", "[LPN] ...: BP 132/78, HR 79, RR 16, Temp 97.9°F, SpO2 97% RA. Resident reports pain 3/10 at right hip with movement; medicated with s..."