End of first 14-day period summary note for Patricia Guillory. Resident continues skilled nursing care for congestive heart failure (I50.9). Overall status: improving. Weight trend: 187 lbs on admission to 182 lbs today, reflecting positive response to diuresis. Bilateral LE edema decreased to trace-1+ bilaterally. O2 sat consistently 94-96% on room air at rest over past 3 days. BP trending lower, ranging 132-144/84-90 this week. Resident ambulating with PT/OT assistance and progressing. Appetite improved; resident consuming approximately 75% of meals. Coccyx redness area remains under monitoring; skin has not worsened. Resident's mood noted to be slightly brighter per CNA report; continues to express motivation to return home. Daughter visited daily and remains engaged in care planning. MD and therapy notified of current status. Care conference tentatively planned for next week to address discharge timeline.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-16
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 2026-04-16
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] ...scribed as poor. Resident also endorses low mood, decreased interest in activities, and poor sleep since hospitalization. Exam: ..."