Current PDGM episode
SOC 2026-03-01
Clinical group
Wound
pos 2: C
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,192
weight 1.09
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
E11.621
Type 2 diabetes mellitus with foot ulcer
D64.9
Anemia, unspecified
F41.9
Anxiety disorder, unspecified
I48.91
Unspecified atrial fibrillation
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit. Pt with chronic diastolic heart failure reports increased shortness of breath since yesterday evening; states woke up once overnight unable to lie flat — pillow count increased from 1 to 3. Wt 189 lbs, up 4 lbs from 6/25 visit. BP 148/90, HR 82 reg, RR 20, SpO2 93% on RA. Bilateral crackles noted at lung bases. Bilateral lower extremity edema 2+ to mid-calf. Pt denies chest pain. NP contacted immediately; orders received to administer supplemental O2 2L NC, increase furosemide to 80 mg x1 dose today, repeat weight tomorrow morning, and proceed to ED if SpO2 does not improve or symptoms worsen. Family member present and educated on worsening HF signs. Follow-up call scheduled for tomorrow 0800.
NP face-to-face visit for ongoing management of chronic diastolic heart failure (I50.32). Reviewed recent weight trend — weights stable at 184-185 lbs over past week. BP 130/76, HR 68, SpO2 97% RA. No jugular venous distension. Lungs clear. Pedal edema absent. Patient reports improved exercise tolerance and energy since last medication adjustment. Current regimen: furosemide 40 mg daily, carvedilol 12.5 mg BID, lisinopril 10 mg daily — continue as ordered. Labs reviewed: BMP from 6/20 shows BUN 22, Cr 1.1, K 4.2 — within acceptable limits. No medication changes at this time. Repeat BMP in 4 weeks. Patient educated on importance of continued HH services and adherence to fluid and sodium restrictions.
Skilled nursing visit. Chronic diastolic heart failure — ongoing monitoring. Wt 185 lbs, down 2 lbs from 6/15 visit; pt reports compliance with furosemide and low-sodium diet. BP 132/78, HR 70 reg, RR 16, SpO2 97% on RA. Bilateral ankle edema resolved. Lung sounds clear bilaterally. No dyspnea at rest; mild dyspnea noted only with stair climbing. Reviewed medication list; carvedilol and lisinopril doses verified. Reinforced importance of daily weights and fluid restriction to 1.5L/day. Skin intact; no breakdown noted. Pt verbalized understanding of HF action plan and when to seek emergency care. No changes to orders required at this time.
Physical therapy visit for functional mobility and endurance training in context of chronic diastolic heart failure with associated deconditioning. Pt tolerated 10-min low-intensity ambulation in hallway with rolling walker; HR peaked at 88, SpO2 maintained 94-96%. Berg Balance Scale score 38/56. Performed seated lower extremity strengthening exercises x2 sets, 10 reps each. Pt reports fatigue at moderate level but no chest pain or significant dyspnea during session. Educated on rate of perceived exertion scale and activity pacing. Goal: improve safe ambulation distance and reduce fall risk. Continue PT 2x/week per plan of care.
Skilled nursing visit for chronic diastolic heart failure monitoring. Pt alert and oriented x3. VS: BP 138/82, HR 74 reg, RR 18, SpO2 95% on RA, wt 187 lbs (up 2 lbs from last visit). Bilateral ankle edema 1+ noted. Lung sounds clear to auscultation. Pt reports mild exertional dyspnea with ADLs. Furosemide compliance confirmed via pill count. Reviewed sodium restriction diet and daily weight log. Instructed pt to call MD if weight increases >2 lbs in 24 hrs or >5 lbs in one week. No chest pain reported. MD notified of weight gain; continue current medication regimen per orders.