Nursing reassessment completed for Evelyn Hartman, day 11 of SNF admission. Resident remains alert, oriented to person and intermittently to place. Mood appears somewhat improved per resident and daughter report; continues to have tearful episodes in evenings. Vitals stable: BP 144/82 mmHg, HR 74 bpm, Temp 98.2°F, SpO2 97% RA. Right heel Stage 2 pressure injury reviewed; wound measures 2.8 x 1.9 cm, pink granulating tissue present, no signs of infection. Resident tolerating nectar-thick liquids and minced-moist diet without overt coughing episodes noted at meals. Transfer status improving per PT/OT reports; now requires moderate assist x2 for bed-to-wheelchair transfers. Incontinent of urine; on scheduled toileting program q2h with moderate success. Skin repositioning q2h maintained. Care conference scheduled for 3/19/2026 with family and interdisciplinary team.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-19
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 2026-03-19
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
O0100F2Ventilator/Respirator Post-admit···☐ NOT CODED
Gap detection · grounded
claude-opus-4-7 · 847ms · 2.1k tok
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...BP 144/82 mmHg, HR 74 bpm, Temp 98.2°F, SpO2 97% RA. Right heel Stage 2 pressure injury reviewed; wound measures 2.8 x 1.9 c...", "[LPN] ...igns: BP 142/84 mmHg, HR 80 bpm, RR 16, SpO2 97%. Resident c/o mild right hip discomfort; no visible deformity or swelling. ..."