87y · female · payer: medicare · SOC: 2025-07-22 · status: discharged
Current PDGM episode
SOC 2025-07-22
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
I50.9
Heart failure, unspecified
D64.9
Anemia, unspecified
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3 unspecified
I48.91
Unspecified atrial fibrillation
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 136/80 (improved since lisinopril dose increase 7/31), HR 74 reg, RR 16, SpO2 96% on RA, wt 161 lbs. No peripheral edema noted today. Lungs clear to auscultation bilaterally. Pt reports sleeping flat without dyspnea — significant improvement from SOC. Updated med list with lisinopril 20 mg change per NP order; pt educated on dosing change and potential dizziness. Confirmed BMP drawn at outpatient lab this morning. Pt and daughter engaged and adherent. PT reports pt tolerating therapy well. Continue current plan of care; RN to visit 2x/week.
F2F telehealth visit conducted with patient and daughter present. Pt with known chronic diastolic heart failure. Reviewed home health nursing reports and daily weight log — net fluid loss of 3 lbs since SOC, edema improving. Current medications reviewed; furosemide dose appropriate, no changes at this time. BP trending high; will increase lisinopril to 20 mg daily — communicated to home health RN for med reconciliation update. SpO2 goal >93% on RA; RN to notify if consistently below. Pt counseled to continue fluid and dietary restrictions. Labs (BMP) ordered; pt to have drawn at outpatient lab by 08/05. Follow-up call in 2 weeks.
Initial PT evaluation. Pt referred for gait training and fall risk reduction secondary to deconditioning in setting of chronic diastolic heart failure. Pt reports fatigue and SOB limiting mobility. MMT bilateral LE: 3+/5 throughout. Gait assessed with standard walker — slow, shuffling pattern, moderate assist required on stairs. Berg Balance Score: 32/56 (moderate fall risk). HR 80 at rest, 96 post 10-ft ambulation; pt reported dyspnea at 4/10 at peak. Functional goals established: ambulate 150 ft independently with walker, safely negotiate 4 steps. HEP initiated with seated LE strengthening. Plan: 3x/week x 4 weeks. MD notified of eval findings.
Follow-up skilled nursing visit. Pt with chronic diastolic heart failure. VS: BP 142/84, HR 76 reg, RR 17, SpO2 95% on RA, wt 162 lbs (down 2 lbs since SOC). Bilateral ankle edema reduced to trace. Lung sounds improved; crackles less prominent at bases. Pt reports sleeping with 2 pillows last night — improvement noted. Reviewed daily weight log; pt documenting consistently. Reinforced sodium restriction and medication adherence. Pt correctly verbalized reportable symptoms (wt gain >2 lbs/day, increased SOB, worsening edema). No acute distress. PT evaluation scheduled this week for functional mobility and fall risk.
SOC visit. Pt is an 81 y/o female with chronic diastolic heart failure. VS: BP 148/88, HR 78 reg, RR 18, SpO2 94% on RA, wt 164 lbs. Bilateral 1+ pitting edema noted ankles/lower legs. Lung sounds with bibasilar crackles. Pt reports 3-pillow orthopnea and dyspnea on exertion with ADLs. Med reconciliation completed; pt on furosemide 40 mg daily, carvedilol 6.25 mg BID, lisinopril 10 mg daily. Pt verbalized understanding of daily weight log. Instructed on low-sodium diet (<2g/day), fluid restriction, and when to call MD. Safety assessment completed. Care plan established. Next RN visit in 2 days.