76y · female · payer: managed_medicare · SOC: 2026-04-02 · status: active
Current PDGM episode
SOC 2026-04-02
Clinical group
MMTA — Other
pos 2: A
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,111
weight 1.05
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
G20
Parkinson's disease
D64.9
Anemia, unspecified
I48.91
Unspecified atrial fibrillation
N18.30
Chronic kidney disease, stage 3, unspecified
I50.32
Chronic diastolic heart failure
F41.9
Anxiety disorder, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled nursing visit, chronic diastolic heart failure monitoring. Weight 161.2 lbs, up 1.4 lbs from last visit 4/18. Pt reports slight increase in ankle swelling x 1 day and ate salty soup yesterday. BP 150/88, HR 74 reg, O2 sat 94% RA, RR 16. Lung sounds clear. LE edema 1–2+ bilateral, no worsening dyspnea or orthopnea. Reinforced sodium restriction — reviewed food label reading and high-sodium foods to avoid. Pt verbalized understanding and committed to dietary adherence. Notified NP via telephone; no medication changes ordered at this time. Instructed to call agency if weight increases further. Revisit in 48 hours.
F2F telehealth visit for oversight of home health plan of care. Pt with chronic diastolic heart failure (I50.32), recently started HH services 4/2. Reports improved dyspnea and reduced edema per nursing documentation. Current weight 159.8 lbs, stable over last week. Reviewed labs from 4/12: BMP WNL, BUN 22, Cr 1.1, K+ 4.2. Furosemide and metoprolol doses appropriate; no changes at this time. Continue current POC. Pt encouraged to maintain low-sodium diet and daily weights. HH team to notify if weight gain >3 lbs in 48 hours or worsening respiratory status. RTC outpatient clinic in 3 weeks.
Initial PT evaluation, pt with chronic diastolic heart failure (I50.32) and associated functional decline. Pt presents with decreased activity tolerance and generalized deconditioning. Gait assessed: ambulates with rolling walker x 30 feet with 1 rest break, mild DOE noted. Berg Balance Score 36/56 — moderate fall risk. Lower extremity strength 3+/5 bilateral. Established HEP focusing on seated LE strengthening, standing balance, and graded ambulation progression. Educated pt on energy conservation techniques and symptom monitoring during activity. Pt tolerated session well, HR and O2 sat remained within acceptable limits. Plan: 2x/week x 4 weeks.
Skilled nursing visit, chronic diastolic heart failure management. Weight today 160.1 lbs, down 2.3 lbs since 4/3. BP 142/82, HR 68, O2 sat 95% RA. Bilateral LE edema improved to 1+. Lung sounds clearer bilaterally. Pt reports improved energy and less dyspnea on exertion walking to bathroom. Medication compliance confirmed; furosemide taken daily as prescribed. Reviewed heart failure action plan — instructed to call if weight increases >2 lbs overnight or >5 lbs in one week. No chest pain, no orthopnea reported. Continue current plan of care.
Initial skilled nursing visit post-SOC. Pt is an 81yo F with chronic diastolic heart failure (I50.32). Vitals: BP 148/86, HR 72 reg, RR 18, O2 sat 94% RA, weight 162.4 lbs. Lower extremity pitting edema 2+ bilateral. Lung sounds with mild bibasilar crackles. Reviewed medication regimen including furosemide 40mg QD and metoprolol succinate 25mg QD — pt verbalized understanding of purpose. Instructed on daily weight monitoring; scale placed bedside. Sodium-restricted diet reinforced. Pt alert, cooperative. Daughter present and engaged. Follow-up visit scheduled in 48 hours.