Current PDGM episode
SOC 2026-03-19
Clinical group
MMTA — Endocrine
pos 2: I
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,815
weight 1.4
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
E11.65
Type 2 diabetes mellitus with hyperglycemia
D64.9
Anemia, unspecified
I48.91
Unspecified atrial fibrillation
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3, unspecified
F41.9
Anxiety disorder, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit. Pt with chronic diastolic heart failure. VS: BP 134/80, HR 76 reg, RR 16, SpO2 97% RA, wt 163 lbs — downward trend sustained, total 4-lb loss since SOC. No edema noted bilateral lower extremities. Lungs clear. Pt reports sleeping flat without difficulty; denies dyspnea at rest. Participating actively in PT HEP per self-report. Medication adherence confirmed via pill organizer review. Reviewed HF action plan — pt correctly identifies red zone symptoms (SOB at rest, >3 lb gain, chest pain). Caregiver daughter present; education reinforced regarding diet and monitoring. Pt progressing toward goals. No acute concerns.
F2F telehealth visit conducted with pt Patricia Nguyen per HH orders. Chronic diastolic heart failure reviewed. Pt reports improved energy since discharge; weight trending down appropriately at 164 lbs today. BP controlled per RN documentation. SpO2 concern noted from PT eval 3/28 — ordered repeat evaluation next PT visit with portable pulse ox monitoring throughout session. Furosemide dose remains 40mg daily; no adjustment at this time. Lab review: BMP from 3/20 — BUN 22, Cr 1.1, K+ 4.2, all within acceptable limits. Next lab draw ordered in 3 weeks. Continue current HH plan of care. Goals of care confirmed with pt.
Initial PT evaluation. Pt with chronic diastolic heart failure referred for functional mobility and activity tolerance training. Baseline 2-min walk test: 94 meters with modified supervision; SpO2 nadir 92% RA, recovered to 95% within 3 min rest. 5x sit-to-stand: 18 sec. Gait speed 0.6 m/s with standard cane. Lower extremity strength 4/5 bilateral. Pt reports fear of activity due to breathlessness. Goals: improve functional endurance, safe ambulation >150m, reduce fall risk. HEP initiated — seated lower extremity strengthening and diaphragmatic breathing. Next visit Fri. MD notified of baseline SpO2 findings.
Follow-up skilled visit. Chronic diastolic heart failure remains primary focus. VS: BP 138/84, HR 78 reg, RR 16, SpO2 96% RA, wt 165 lbs (down 2 lbs from last visit — positive response to diuresis). Bilateral ankle edema trace. Pt reports mild exertional dyspnea with ADLs but denies orthopnea or PND. Medication reconciliation completed; no discrepancies identified. Reinforced sodium restriction and fluid limits. Pt demonstrates correct use of home scale and diary log. Safety assessment completed — no falls. Home environment assessed; adequate lighting, no significant trip hazards. Care plan updated.
Initial skilled nursing visit post-SOC. Pt Patricia Nguyen, 68F, with chronic diastolic heart failure. VS: BP 148/88, HR 82 reg, RR 18, SpO2 94% RA, wt 167 lbs (up 2 lbs from DC wt). Bilateral ankle edema 1+ noted. Lung sounds clear to auscultation bilaterally. Reviewed daily weight log, low-sodium diet, and fluid restriction 1.5L/day. Furosemide 40mg PO daily confirmed on MAR; pt reports taking consistently. Instructed pt on daily weight parameters and when to call MD (>2 lb gain in 24h). Pt verbalized understanding. Will return in 2 days.