Current PDGM episode
SOC 2025-10-14
Clinical group
Neuro Rehabilitation
pos 2: B
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$2,212
weight 1.1
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
I69.351
Hemiplegia following cerebral infarction affecting right dominant side
D64.9
Anemia, unspecified
I48.91
Unspecified atrial fibrillation
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3, unspecified
F41.9
Anxiety disorder, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Skilled visit, chronic diastolic heart failure. VS: BP 130/76, HR 72 reg, RR 14, SpO2 97% RA, wt 161.8 lbs (stable). No peripheral edema noted. Lungs clear all fields. Patient reports sleeping flat comfortably, tolerating ADLs with mild fatigue only. Reviewed lab order for BMP per NP — patient verbalized understanding of draw date. Reinforced dietary sodium and fluid restrictions; patient accurately states daily weight process and warning symptoms. Home safety reviewed — clear pathways, nightlight in hallway. Patient expresses confidence in self-management. Continue current HH plan of care.
F2F telehealth visit for oversight of chronic diastolic heart failure management. Reviewed recent weight trend and RN notes — fluid status improved. Current medications reviewed: furosemide 40mg daily, lisinopril 10mg daily, carvedilol 6.25mg BID. BP well-controlled today per patient report (132/80 this AM). No chest pain, no new orthopnea. Plan: continue current regimen, no medication changes at this time. Ordered repeat BMP in 2 weeks to monitor renal function and potassium. Patient instructed to call if weight increases >2 lbs in 24 hours. Follow-up in 30 days or PRN.
PT skilled visit for functional mobility and exercise tolerance secondary to chronic diastolic heart failure deconditioning. Patient ambulated 120 feet in hallway with supervision, no assistive device; gait steady, no SOB at conclusion (Borg RPE 3/10). HR pre-exercise 76, post-exercise 92, recovered to 80 within 3 minutes. Performed seated lower-extremity strengthening x10 reps bilaterally. Instructed patient in energy conservation techniques for household tasks. Short-term goal: ambulate 200 feet independently without exertional symptoms. Patient motivated and engaged. Next visit in 3 days.
Follow-up skilled visit, chronic diastolic heart failure. VS: BP 132/78, HR 74 reg, SpO2 97% RA, wt 162.6 lbs (down 1.6 lbs since 11/01). Edema resolved bilaterally. Patient reports improved energy; completed morning ADLs without dyspnea. Lungs clear. Medication reconciliation completed — all medications accurate, patient verbalizes correct furosemide dosing and hold parameters. Reinforced symptom reporting: weight gain >2 lbs/day, increased SOB, or leg swelling. Care plan updated to reflect improved fluid status. Continue current plan.
Skilled visit for chronic diastolic heart failure monitoring. VS: BP 138/82, HR 78 reg, RR 16, SpO2 96% RA, wt 164.2 lbs (up 1.8 lbs from last visit). Bilateral ankle edema 1+. Lungs CTA bilaterally, no crackles. Patient reports mild fatigue with ADLs, denies orthopnea or PND. Reviewed daily weight log — patient compliant. Reinforced 2g sodium diet and fluid restriction of 1.5L/day. Furosemide 40mg PO daily confirmed on MAR. Notified PCP of weight gain trend. Return visit in 3 days.