77y · male · payer: managed_medicare · SOC: 2026-02-07 · status: active
Current PDGM episode
SOC 2026-02-07
Clinical group
MMTA — Respiratory
pos 2: L
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$3,117
weight 1.55
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
J18.9
Pneumonia, unspecified organism
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
Incident report: Upon arrival for scheduled skilled visit, pt reports near-fall in bathroom at approximately 0630 this morning. Pt states felt lightheaded rising from toilet; steadied self on grab bar without reaching floor, no injury sustained. VS: BP 118/70 sitting, 104/64 standing — orthostatic drop of 14 mmHg systolic noted. HR 80 reg, SpO2 95%. No acute distress. Assessed for injuries — none identified. In context of chronic diastolic heart failure and diuretic therapy, orthostatic hypotension considered contributing factor. MD/NP notified; advised to hold morning furosemide dose and recheck standing BP tomorrow. Safety education provided: slow position changes, use of grab bars. Incident documented per agency policy. RTC tomorrow for BP recheck.
Face-to-face visit for ongoing management of chronic diastolic heart failure (I50.32). Pt reports improved functional status since SOC. Current wt 185.2 lbs, BP 130/76, HR 72 reg, SpO2 96% RA. Trace bilateral ankle edema. Lungs clear. Labs reviewed: BMP from 06/10 — BUN 18, Cr 1.1, K+ 4.2, all WNL. Furosemide dose appropriate; no adjustment indicated at this time. Confirmed medication compliance. Continued home health services ordered: RN 2x/week x 4 weeks, PT 1x/week x 4 weeks. Pt/family questions addressed. Follow-up in office in 3 weeks or sooner PRN.
PT skilled visit for therapeutic exercise and functional mobility. Pt with chronic diastolic heart failure; activity tolerance remains primary focus. Completed 10-min low-intensity ambulation in home with RatePE 11/20 (Borg scale). No angina or significant dyspnea noted; SpO2 maintained 94–96% throughout. Gait steady with rolling walker on level surfaces; increased caution on carpeted bedroom threshold. Educated pt on energy conservation techniques and activity pacing to minimize cardiac exertion. HEP reviewed: seated marching, ankle pumps, standing heel raises x10 reps BID. Pt demonstrates good understanding. Goal: ambulate 15 min continuously without desaturation by next week.
Follow-up skilled visit per MD instruction re: 2.2 lb weight gain. Today wt 185.8 lbs, down 1.6 lbs. BP 132/78, HR 74 reg, SpO2 96% RA. Edema improved to trace bilateral ankles. Pt reports improved energy, denies SOB at rest. Lung sounds clear. Pt verbalized understanding of when to call MD (weight gain >2 lbs/day, increased swelling, worsening SOB). Medication reconciliation completed — no discrepancies. Reinforced dietary restrictions for chronic diastolic heart failure. Plan: continue current frequency, reassess next visit.
Skilled visit for chronic diastolic heart failure management. VS: BP 138/82, HR 78 reg, RR 16, SpO2 95% RA, wt 187.4 lbs (up 2.2 lbs from last visit). Bilateral ankle edema 1+ noted. Lung sounds clear bilaterally. Pt denies chest pain; reports mild dyspnea on exertion with 2 flights of stairs. Reviewed daily weight log — pt compliant. Reinforced 2g sodium diet and fluid restriction of 1.5L/day. Furosemide 40mg PO daily confirmed on MAR. MD notified of weight gain; instructed to continue current regimen and recheck weight in 48 hrs. RTC 2 days.