Current PDGM episode
SOC 2026-02-28
Clinical group
Musculoskeletal Rehabilitation
pos 2: E
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,272
weight 1.13
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
Z47.1
Aftercare following joint replacement surgery
D64.9
Anemia, unspecified
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3 unspecified
F32.9
Major depressive disorder, single episode, unspecified
E03.9
Hypothyroidism, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit. Pt with chronic diastolic heart failure (I50.32) reporting improved energy and reduced dyspnea compared to last week. Weight stable at 161 lbs x2 days. BP 138/82, HR 70 reg, RR 16, SpO2 96% RA. Bilateral ankle edema resolved to trace. Lung sounds clear bilaterally. BMP results from 3/9 reviewed: K+ 3.8, BUN/Cr stable. Potassium supplement continuing. Medication adherence confirmed; pill organizer in use. Pt maintaining daily weight log correctly; correctly states 2-lb alert threshold. Wound, skin intact. Goals being met; discussed progression toward discharge planning with pt and daughter. Next RN visit 3/17.
Physical therapy skilled visit. Pt with chronic diastolic heart failure; cleared by RN for therapy initiation per cardiologist guidelines. Baseline functional assessment completed. Pt ambulates 15 feet with rolling walker, mod assist x1, SpO2 drops to 91% with exertion, returns to 94% within 2 min at rest. HR 78 at rest, 96 at peak exertion. Berg Balance Score 32/56; fall risk elevated. HEP initiated: seated lower extremity strengthening, diaphragmatic breathing, ankle pumps. Energy conservation techniques reviewed. ST goals: improve ambulation to 50 feet, decrease fall risk. Pt motivated; daughter supportive. Next visit 3/12.
NP telehealth follow-up visit for Gloria Reyes, chronic diastolic heart failure (I50.32). Reviewed RN notes from 3/5 documenting 4-lb weight gain and dyspnea on exertion. Pt reports modest improvement after furosemide dose increase; weight down to 162 lbs per this morning's log. BP 146/86, HR 74 per RN on-site measurement shared. SpO2 94% RA. Plan: continue furosemide 80mg daily x2 more days, then revert to 40mg. Add potassium 20mEq daily given diuretic escalation. Labs (BMP) ordered for 3/9. Continue HH nursing oversight. Pt and daughter with questions answered. Follow-up scheduled.
Follow-up skilled nursing visit. Pt reports increased shortness of breath with ambulation to bathroom since yesterday. Weight today 165 lbs, up 4 lbs from 3/2 visit. BP 154/92, HR 80 reg, SpO2 93% on RA. Bibasilar crackles more pronounced. Physician notified of weight gain and worsening symptoms; Dr. Nguyen order received to increase furosemide to 80mg daily x3 days. Pt instructed to elevate legs, limit activity, and monitor symptoms closely. Emergency signs and symptoms reviewed. Caregiver daughter present and educated. Will reassess in 48 hours.
Skilled nursing visit completed. Pt is Gloria Reyes, admitted 2/28 with chronic diastolic heart failure (I50.32). VS: BP 148/88, HR 72 reg, RR 18, SpO2 95% on RA, weight 163 lbs (up 2 lbs from SOC). Bilateral pitting edema noted in ankles, 1+. Lung sounds with mild bibasilar crackles. Reviewed low-sodium diet and daily weight log. Reinforced fluid restriction 1.5L/day. Medication reconciliation completed; pt taking furosemide 40mg daily, lisinopril 10mg daily as prescribed. Call MD if weight gain >2 lbs in 24 hrs. Pt verbalized understanding. Return visit scheduled.