Current PDGM episode
SOC 2025-06-30
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
I48.91
Atrial fibrillation, unspecified
D64.9
Anemia, unspecified
F41.9
Anxiety disorder, unspecified
N18.30
Chronic kidney disease, stage 3 unspecified
I50.32
Chronic diastolic heart failure
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit. Pt with chronic diastolic heart failure. VS: BP 136/80, HR 76 bpm, O2 sat 96% on RA, weight 184 lbs (stable x5 days). Bilateral ankle edema resolved. Lung sounds clear throughout. BMP results reviewed: BUN 22, creatinine 1.1, potassium 3.7 — all within acceptable limits; notified NP, no new orders. Lisinopril dose increase tolerated well per pt report. Reinforced daily weight log compliance; pt demonstrating consistent AM weights before breakfast. Pt and wife verbalize three reportable s/sx correctly: weight gain >2 lbs overnight, increased dyspnea, worsening edema. Pt progressing toward goals. Continue current POC.
F2F telehealth visit for home health certification. Pt is a 74 y/o male with primary diagnosis chronic diastolic heart failure (I50.32). Reviewed recent nursing and PT notes. Weight trending down appropriately; edema improving. Current regimen: furosemide 40 mg daily, metoprolol succinate 50 mg, lisinopril 10 mg. BP slightly elevated today per RN report — increasing lisinopril to 20 mg daily. Labs ordered: BMP to check renal function and potassium given diuretic therapy. Pt remains homebound secondary to dyspnea on exertion and fall risk. Certifying home health services. Follow-up in 30 days or sooner PRN.
Initial PT evaluation. Pt referred for therapeutic exercise and functional mobility secondary to deconditioning related to chronic diastolic heart failure. Pt reports fatigue and dyspnea with minimal exertion. Baseline 6MWT completed in home: 210 feet with 1 rest break; O2 sat nadir 91%, recovered to 95% within 2 min. Berg Balance Score 42/56 — moderate fall risk. Lower extremity strength 4-/5 bilateral. Established POC: therapeutic exercise, balance training, energy conservation techniques, HEP. Goals: improve 6MWT to 350 feet, Berg to 48/56 within 60 days. Pt agreeable and motivated. Caregiver present and instructed in guarding techniques.
Skilled nursing visit. Pt with chronic diastolic heart failure. VS: BP 142/84, HR 78 bpm, O2 sat 95% on RA, weight 185 lbs (down 2 lbs from baseline — positive response to diuresis). Edema improved to trace bilateral. Lung sounds clearer today, no crackles auscultated. Pt reports improved energy and less shortness of breath with ADLs. Reviewed low-sodium diet log with wife; identified hidden sodium in canned soups, provided written handout. Pt adherent to medications. No s/sx of orthostatic hypotension. Notified MD of weight trend — no new orders at this time. Plan: continue monitoring.
SOC follow-up visit. Pt is a 74 y/o male with chronic diastolic heart failure. VS: BP 148/88, HR 82 bpm, RR 18, O2 sat 94% on RA, temp 98.2°F. Weight 187 lbs (baseline established). Bilateral +1 pitting edema ankles. Lungs with fine basilar crackles bilateral. Pt reports mild dyspnea on exertion, denies chest pain. Medication reconciliation completed; furosemide 40 mg daily, metoprolol succinate 50 mg confirmed. Educated pt and wife on daily weights, sodium restriction <2g/day, and s/sx to report. Pt verbalized understanding. Will continue skilled nursing visits 3x/week.