Day 9 nursing progress note. Resident Margaret Holloway continues to demonstrate gradual improvement in alertness and engagement; oriented x1-2 on this shift. Tolerating nectar-thick liquids and minced diet per SLP recommendation without observed coughing episodes. Voiding independently to commode with assist x1 since Foley removal; continent of bladder. Coccygeal wound reassessed: wound measures 2.8 cm x 1.8 cm, pink granulation tissue present, no signs of infection or undermining. Resident repositioned every 2 hours per turning schedule; pressure-relieving mattress in place. Sertraline initiated per MD order; no adverse effects noted to date. BP today 136/80. Mood remains low; resident tearful during evening care. Will continue to monitor and support per care plan.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-04
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 2026-03-04
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] ...86 mmHg, HR 78 bpm, RR 16, Temp 98.4°F, SpO2 96% on room air. Alert but oriented x1 (self only). Demonstrates expressive aph..."