Nurse practitioner follow-up visit, day 10 of SNF stay. Mr. Watkins continues to progress with treatment for congestive heart failure (I50.9). Weight today 193 lbs, down 5 lbs from admission. Bilateral lower extremity edema trace to absent. Lung sounds clear to auscultation bilaterally — significant improvement from admission. O2 sat 96% on 2L NC at rest; trialing room air with saturation maintained at 94–95% x 30 minutes — will attempt wean to room air with close monitoring. BP 130/82, HR 80 irregular. Resident reports improved energy and less dyspnea with activities. PT/OT report functional gains with transfers now requiring minimal assist of 1. Resident continues to endorse low mood and reduced enjoyment of daily activities; discussed with care team. Furosemide dose reduced to 20mg daily given improved volume status. Continue all other current medications. Follow-up visit in 4 days. Discharge planning discussion initiated with social services and therapy team.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-18
I0900Peripheral Vascular Disease···☐ NOT CODED
I2000Pneumonia···☐ NOT CODED
I2500Wound Infection···☐ NOT CODED
I3500Pressure Ulcer Stage 3···☐ NOT CODED
I4500Diabetes Mellitus···☐ NOT CODED
MDS · Section O — Special Treatments · target 2026-03-18
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···✓
O0100F2Ventilator/Respirator Post-admit···✓
Gap detection · grounded
claude-opus-4-7 · 847ms · 2.1k tok
DEPRESSIONmedium
Notes describe depressive symptoms. Score a PHQ-9 (D0150) or staff assessment (D0500) at next MDS to capture for nursing classification.
Field: pdpmDepression
Evidence: "[NP] ...ist of 1. Resident continues to endorse low mood and reduced enjoyment of daily activities; discussed with care team. Furosemide...", "[MD] ...rmur appreciated. Patient also endorses low mood, poor sleep, and diminished interest in activities since hospitalization. Will ..."