Current PDGM episode
SOC 2025-08-05
Clinical group
MMTA — Cardiac & Circulatory
pos 2: H
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,513
weight 1.25
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
I50.32
Chronic diastolic (congestive) heart failure
D64.9
Anemia, unspecified
F32.9
Major depressive disorder, single episode, unspecified
I48.91
Unspecified atrial fibrillation
N18.30
Chronic kidney disease, stage 3 unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Incident report: Pt found by daughter on floor of bedroom approximately 1400. Pt reports rising from bed unassisted without walker and lost balance, landed on R side. Denies LOC, no head strike per pt and daughter. C/o mild R hip discomfort. VS: BP 152/90, HR 88, O2 sat 94%. No visible deformity, skin intact, able to perform active ROM bilateral LEs with pain rated 2/10 R hip. Pt assisted back to bed. MD/NP on-call notified — order received to monitor; ER referral if pain worsens or inability to bear weight. Daughter reinforced on fall prevention: always use walker, call for assistance. Safety reassessment completed. PT notified. Incident documented per agency protocol.
Face-to-face home visit for plan of care review. Pt Harold Brinkley with chronic diastolic CHF, I50.32. Weight trend improving — down 3 lbs since SOC. BP 138/82, HR 76, O2 sat 95% RA at rest. Bibasilar crackles resolving; trace bilateral ankle edema. Pt reporting improved energy. Current regimen appropriate; no medication changes at this time. Ordered repeat BMP in 2 weeks to monitor renal function and electrolytes given furosemide use. Reviewed 60-day POC — certifying skilled nursing 3x/week and PT 2x/week. Pt and family agreement obtained. Follow up with cardiology scheduled 09/15/2025.
Initial PT evaluation. Pt referred for functional mobility and fall risk assessment in context of chronic diastolic heart failure with associated activity intolerance. Berg Balance Scale score 42/56 — moderate fall risk. Ambulates with standard walker x 30 feet before reporting dyspnea and fatigue, O2 sat dropping to 92% on RA with exertion. Transfers sit-to-stand requiring minimal assist. PT goals: improve ambulatory tolerance to 150 feet, independence with walker on level surfaces, HEP education. Initiated therapeutic exercise program — seated LE strengthening and breathing techniques. Caregiver instructed in guarding technique. Pt tolerated session well. PT to see 2x/week x 6 weeks.
Follow-up skilled nursing visit. Pt reports mild dyspnea on exertion when ambulating to bathroom, denies orthopnea. Weight today 187.8 lbs, down 1.6 lbs from last visit — trending appropriately. BP 142/84, HR 78 reg, O2 sat 95% RA. Ankle edema unchanged at 1+. Reinforced CHF disease management: fluid restriction 1.5L/day, daily weights, symptom monitoring. Reviewed medication compliance — no missed doses reported. Pt demonstrating improved understanding of CHF self-management. Caregiver (daughter) present, educated on red flag symptoms requiring 911 activation. Plan: continue skilled visits 3x/week.
SOC follow-up visit. Pt Harold Brinkley, 72 y/o male with chronic diastolic CHF. VS: BP 148/88, HR 82 reg, RR 18, O2 sat 94% on RA, weight 189.4 lbs. Bilateral 1+ pitting edema ankles. Lungs with faint bibasilar crackles. Reviewed med regimen — pt taking furosemide 40mg QD and lisinopril 10mg QD correctly. Reinforced daily weight log and instructed to call if weight increases >2 lbs overnight or >5 lbs in one week. Pt verbalized understanding. Dietary sodium restriction reviewed. RN to return in 3 days.