PT progress note — Day 10 post-admission. Mr. Tanaka continues skilled PT daily focused on gait retraining, balance, and functional mobility following sequelae of cerebral infarction. Resident demonstrating measurable progress: ambulated 45 feet with rolling walker and contact guard assist x1 today, improved from 10 feet with moderate assist x2 at evaluation. Right LE strength improving — 3-/5 at hip flexors and knee extensors. Berg Balance Scale re-administered: score 26/56, improvement of 8 points from baseline. Transfer training: sit-to-stand now requiring moderate assist x1, notable improvement from 4-person assist at evaluation. AFO fitting completed 04/03; resident tolerating device well and wearing during all therapy sessions and ambulation. Resident motivated and engaged. Continues to demonstrate fall risk; precautions maintained. Recommend continued skilled PT to achieve home discharge goals.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-10
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 2026-04-10
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: "[NP] ...indings are consistent with post-stroke depression, which is common following cerebral infarction. Will continue to monitor mood. ...", "[MSW] ...ll be explored. Resident denies current depressed mood but son notes he has been 'very quiet and withdrawn' since hospitalization..."