Current PDGM episode
SOC 2025-11-03
Clinical group
MMTA — Respiratory
pos 2: L
Functional impairment
Medium
pos 3: B
Comorbidity
Low
pos 4: B
30-day payment
$3,117
weight 1.55
OASIS-E assessment
Function (M1800-M1860)
Comorbidity & risk
Mobility / wound
Diagnoses
J44.9
Chronic obstructive pulmonary disease, unspecified
D64.9
Anemia, unspecified
F32.9
Major depressive disorder, single episode, unspecified
I50.32
Chronic diastolic heart failure
N18.30
Chronic kidney disease, stage 3 unspecified
E03.9
Hypothyroidism, unspecified
E78.5
Hyperlipidemia, unspecified
I10
Essential (primary) hypertension
Visit notes
Face-to-face visit for chronic diastolic heart failure recertification and medication review. Pt hemodynamically improved from exacerbation earlier this month. Current weight 161 lbs, BP 138/84, HR 70 reg, SpO2 96% RA. No acute respiratory distress. Edema resolved. Reviewed recent RN notes and PT progress. Furosemide returned to 40mg daily as ordered. ACE inhibitor and beta-blocker doses confirmed appropriate. Dietary sodium adherence improving per RN report. Certified continued skilled home health services — HH remains medically necessary for skilled nursing monitoring and PT to address functional deficits and fall risk. Follow-up in office in 4 weeks or sooner if decompensation.
Urgent revisit per physician order following weight gain. Pt with chronic diastolic heart failure. Weight 163 lbs — 2 lb decrease from yesterday. BP 142/86, HR 74, RR 18, SpO2 95% RA. Pt reports improved breathing, ankle edema reduced to trace bilaterally. Lung sounds clearer, crackles resolved. Tolerating increased furosemide without dizziness or electrolyte complaints. Reviewed potassium-rich food sources given diuretic adjustment. Reinforced daily weight log — pt now documenting consistently. Dr. Patel notified of improvement; continue furosemide 80mg through 11/15 then return to 40mg daily. Plan: continue twice-weekly skilled visits for hemodynamic monitoring.
Follow-up skilled nursing visit. Pt with chronic diastolic heart failure. Weight today 165 lbs — 3 lb gain since 11/05 visit. Reported mild increase in ankle swelling and mild dyspnea at rest. BP 154/92, HR 78, RR 20, SpO2 93% RA. Bibasilar crackles more prominent bilaterally. Notified attending physician Dr. Patel per protocol; order received to increase furosemide to 80mg daily x3 days, recheck weight tomorrow. Pt instructed to elevate legs, restrict fluids to 1.5L/day, and call agency if symptoms worsen overnight. Caregiver (daughter) present and educated on s/s of decompensation. Plan: urgent RN revisit tomorrow for weight and symptom reassessment.
Initial PT evaluation for chronic diastolic heart failure with associated functional decline and fall risk. Pt reports dyspnea on exertion with minimal activity. Ambulates with rolling walker, gait slow and cautious. Timed Up and Go: 22 seconds — elevated fall risk. Lower extremity strength 3+/5 bilaterally. SpO2 dropped to 92% after 10-ft walk, recovered to 95% with 2-min rest. Functional goals: improve ambulation tolerance to 150 ft and reduce TUG to <15 sec in 6 weeks. HEP initiated with seated LE strengthening exercises. Patient cooperative and motivated. Next visit in 2 days.
Skilled nursing visit for chronic diastolic heart failure management. Pt alert, oriented x3. VS: BP 148/88, HR 72 reg, RR 18, SpO2 95% RA, weight 162 lbs (baseline per SOC 160 lbs). Bilateral ankle edema 1+ noted. Lung sounds with mild bibasilar crackles. Reviewed low-sodium diet and fluid restriction compliance — pt reports eating canned soup daily, counseled re: sodium content. Medication reconciliation completed; furosemide 40mg daily confirmed. Pt verbalized understanding of daily weight log and when to call physician (>2 lb gain in 24 hrs). Plan: continue skilled monitoring, f/u weight trend next visit.