Current PDGM episode
SOC 2025-09-18
Clinical group
Musculoskeletal Rehabilitation
pos 2: E
Functional impairment
Medium
pos 3: B
Comorbidity
High
pos 4: C
30-day payment
$2,533
weight 1.26
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
S72.001D
Fracture of unspecified part of neck of right femur, subsequent encounter
D64.9
Anemia, unspecified
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3 unspecified
F41.9
Anxiety disorder, unspecified
E03.9
Hypothyroidism, unspecified
I10
Essential (primary) hypertension
E78.5
Hyperlipidemia, unspecified
Visit notes
Skilled nursing visit — Denise Washington, chronic diastolic heart failure. VS: BP 136/80, HR 68 reg, RR 14, O2 sat 97% RA, wt 171.6 lbs. No edema noted bilateral lower extremities. Lung sounds clear throughout. Patient reports sleeping flat without difficulty, no nocturnal dyspnea x 1 week. Reviewed daily weight log — patient consistently documenting, demonstrates appropriate understanding of 2 lb/3-day weight gain action threshold. Skin intact, no new breakdown. Discussed upcoming cardiology appointment 10/22; patient has confirmed transportation. Assessed knowledge of low-sodium diet — patient correctly identified high-sodium foods to avoid. Clinical status improving. Continue current POC.
Face-to-face supervisory visit — Denise Washington. Chronic diastolic heart failure, I50.32, remains primary diagnosis. Patient reports gradual improvement in exertional tolerance since SOC. Current wt 172.0 lbs, BP 138/82, HR 70 reg, O2 sat 97% RA. No peripheral edema noted today. Lungs clear. Cardiology follow-up scheduled 10/22. Reviewed medication list — furosemide 40mg daily, carvedilol 6.25mg BID, lisinopril 10mg daily. All medications continued. Plan of care recertified for additional 60-day episode. Continue skilled nursing 2x/week for HF monitoring and PT 1x/week for progressive exercise. Patient and daughter present, verbalized agreement with plan.
Physical therapy visit — Denise Washington. Patient with chronic diastolic heart failure presenting with activity intolerance and deconditioning. VS pre-exercise: BP 140/86, HR 74, O2 sat 96% RA. Performed 6-minute walk test in home corridor — 210 feet with 1 rest break, O2 sat nadir 93% RA, exertion rated 4/10 Borg. Progressed therapeutic exercise program: seated lower extremity strengthening x10 reps, marching in place 2 min, standing balance at counter. Patient tolerated without complaints of chest pain or significant dyspnea. Educated on energy conservation techniques for household tasks. Goals: improve ambulation tolerance and safety with functional mobility. Next visit Thursday.
Follow-up skilled visit per MD order re: weight gain. Denise Washington, chronic diastolic heart failure. Wt today 172.8 lbs — down 1.4 lbs since 10/01. BP 142/84, HR 72 reg, O2 sat 96% RA. Ankle edema 1+ bilateral, unchanged. Lung sounds clear. Patient reports improved energy, denies orthopnea or PND. Medication reconciliation completed; no new OTC medications or supplements added. Reinforced fluid restriction 1.5L/day and dietary sodium education. Patient verbalized understanding of when to call 911 vs. agency nurse. Weight trending in appropriate direction — will continue monitoring per plan of care.
Skilled nursing visit for Denise Washington. Chronic diastolic heart failure management. VS: BP 148/88, HR 76 reg, RR 16, O2 sat 95% RA, wt 174.2 lbs (up 2.2 lbs from last visit 3 days ago). Bilateral ankle edema 1+ noted. Lung sounds clear bilaterally. Patient reports mild dyspnea on exertion with ADLs. Furosemide 40mg PO daily compliance confirmed; patient demonstrated pill organizer use correctly. Educated on daily weight log, sodium restriction <2g/day, and symptom reporting. MD notified of weight gain — continue current regimen, recheck weight in 48 hours. Return visit scheduled.