OT session day 10 with Ms. Simmons. Resident continues to progress in ADL retraining following pneumonia (J18.9) with associated deconditioning. Grooming at sink: setup assist only, completed task with good safety awareness. Upper body dressing: minimal assist x1 for donning bra and overhead shirt; resident pacing activity well with O2 sat maintaining 94% on room air throughout. Lower body dressing: moderate assist x1, limited by reduced hip flexion and deconditioning. Functional transfer bed to wheelchair: supervision only with verbal cueing. Session focused on energy conservation techniques and adaptive strategies for home environment. Resident engaged and motivated; reports feeling 'much stronger' this week. Continuing OT 5x/week. Anticipate modified independence with most basic ADLs at discharge with home health OT follow-up.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-24
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 2026-04-24
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···✓
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] ...consult ordered. Resident also endorses low mood, poor sleep, and anhedonia, which she attributes to her illness and hospitaliza..."