Nursing progress note — Evelyn Strickland, day 11 post-admission. Resident alert and cooperative. Vital signs stable: BP 130/76, HR 72, Temp 98.6°F, SpO2 97% RA. Appetite improved per CNA report; consuming approximately 70% of meals. Coccygeal pressure injury previously noted on admission reassessed: area measures 1.8x1.5 cm, remains non-blanchable erythema, skin intact, consistent with Stage 1 pressure injury. Resident repositioned Q2H per care plan; pressure-redistributing mattress overlay in place. No new skin breakdown noted. Resident reports mood has improved slightly; states she is 'feeling more hopeful' about going home. Participating in PT and OT without significant refusal. Pain well controlled at 2/10 at rest, 4/10 with therapy. Family visited this afternoon; daughter verbalized satisfaction with care. Continue current plan of care.
MDS 3.0 · Section I — Active Diagnoses · target 2026-02-12
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 2026-02-12
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
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: "[MD] ... noted by staff and social work to have depressed mood, tearfulness, and decreased appetite since admission. Will continue to mon...", "[MSW] ...ness during interview. Will monitor for depressive symptoms and coordinate with interdisciplinary team. Medicare Part A insurance ..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ... stable: BP 130/76, HR 72, Temp 98.6°F, SpO2 97% RA. Appetite improved per CNA report; consuming approximately 70% of meals....", "[RN] ...: BP 138/82, HR 76, RR 16, Temp 98.4°F, SpO2 96% on room air. Resident alert and oriented x2, cooperative with admission ass..."