Current PDGM episode
SOC 2026-01-15
Clinical group
Wound
pos 2: C
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,192
weight 1.09
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
L89.150
Pressure ulcer of sacral region, unspecified stage
D64.9
Anemia, unspecified
I48.91
Unspecified atrial fibrillation
I50.32
Chronic diastolic (congestive) heart failure
N18.30
Chronic kidney disease, stage 3 unspecified
E03.9
Hypothyroidism, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit, chronic diastolic CHF follow-up post NP medication change. Pt weight 208 lbs — down 6 lbs from SOC. BP 136/80, HR 76 irregular, SpO2 95% RA, RR 16. Edema trace bilateral ankles. Lung sounds clear to auscultation. Pt denies dizziness or orthostasis. BMP results reviewed with NP: K+ 3.8, Cr 1.2 — within acceptable limits. Furosemide 40mg BID tolerated without adverse effect. Pt demonstrates accurate technique for daily weight documentation. Educated on potassium-rich food sources given increased diuretic dose. Functional status improving per PT report. Goals being met. Plan to reassess frequency of RN visits next week; may reduce to weekly if trajectory maintained.
F2F telehealth visit for chronic diastolic CHF management. Reviewed RN and PT findings from prior visits. Weight trending down — currently 210 lbs. BP 140/82, pt reports SpO2 93–95% at rest per home monitoring. No acute chest pain, no syncope. Persistent mild exertional dyspnea. Adjusting furosemide to 40mg BID for one week, then reassess. Repeat BMP ordered to monitor potassium and renal function given diuretic uptitration. Continued home health services appropriate. Patient counseled on importance of daily weights and when to present to ED. Will review labs at next telehealth visit in 7 days.
Initial PT evaluation. Pt referred for functional mobility and fall risk reduction in setting of chronic diastolic CHF with deconditioning. Pt reports fatigue with minimal exertion, unsteady gait noted x2 weeks. Functional assessment: ambulates 25 ft with rolling walker, moderate assist, Borg RPE 15/20 at completion. Berg Balance Score 32/56 — high fall risk. Lower extremity strength 3+/5 bilateral. SpO2 monitored throughout; nadir 91% during ambulation, returned to 94% with 3-min rest. PT goals: improve ambulation tolerance to 150 ft with SBA, improve Berg to >45 within 60 days. HEP initiated: seated LE strengthening, ankle pumps. Plan for 2x/week PT visits. MD notified of SpO2 nadir finding.
Follow-up skilled nursing visit for chronic diastolic CHF management. Pt weight today 211 lbs, down 3 lbs since SOC — consistent with diuresis. BP 142/84, HR 78 irregular, SpO2 95% on RA. Edema improved to 1+ bilateral ankles. Crackles persist at left base only. Pt denies chest pain. Reports compliance with furosemide since last visit. Reinforced daily weight protocol: instructed to call agency if weight increases >2 lbs in one day or >5 lbs in one week. Reviewed fluid restriction (1.5L/day) and low-sodium diet. Pt verbalized understanding. Caregiver daughter present, educated on CHF exacerbation warning signs. MD aware of trending improvement.
SOC visit. Pt is 78 y/o male with chronic diastolic CHF. Vital signs: BP 148/88, HR 82 irregular, RR 18, SpO2 93% on RA, weight 214 lbs. Bilateral pitting edema 2+ to ankles. Lung sounds diminished at bilateral bases with fine crackles. Pt reports increased dyspnea on exertion x3 days, sleeping on 2 pillows. Reviewed medication list; furosemide 40mg daily confirmed, pt reports occasional missed doses. Safety assessment completed. Fall risk HIGH. O2 ordered PRN. Plan: daily weight log initiated, low-sodium diet education provided, f/u MD notified of baseline findings. Next RN visit in 2 days.