PT progress note, day 9 of skilled stay. Mr. Mendoza continues to be seen for skilled PT secondary to COPD exacerbation with functional deconditioning. Resident demonstrating measurable progress: transfers now require supervision only with verbal cueing for pacing and pursed-lip breathing. Ambulated 60 feet in hallway with rolling walker and supervision; O2 sat maintained at 92–93% on 2L NC throughout, returning to 95% with brief rest. Resident using pursed-lip breathing technique independently during ambulation. Resident reports decreased dyspnea with activity compared to initial evaluation. Dynamic balance improving; Timed Up and Go: 28 seconds. Resident remains motivated and engaged. Continuing to progress per plan. Coordination with OT and nursing ongoing. Goals remain on track for anticipated discharge to home with home health services.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-01
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 2026-04-01
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···☐ NOT CODED
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: "[MD] ...lace. Resident has also been expressing low mood and reduced enjoyment of activities to nursing staff over the past two days. Wi...", "[MSW] ...scharge. Resident denies any history of depression or substance use. Medicare Part A coverage confirmed; benefits explanation prov..."