End-of-shift nursing note, day 11 of SNF admission. Linda Bergstrom's respiratory status continues to improve; O2 sat 96–97% on room air, transitioned off supplemental oxygen this afternoon per physician order. Lung sounds clearer bilaterally, cough less frequent and now minimally productive. Resident tolerated oral antibiotics well; IV line discontinued yesterday. Appetite improved — consumed 70% of lunch and dinner trays. Resident ambulating in hallway with rolling walker and supervision per PT plan. Mood appears improved; resident participated in card activity in common area this afternoon per activities staff report. Coccyx wound reassessed — Stage 2 pressure injury stable, no signs of infection, dressing changed per protocol. Resident continues on nectar-thick liquids per SLP recommendation. No acute concerns at this time; will continue monitoring.
MDS 3.0 · Section I — Active Diagnoses · target 2026-05-02
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 2026-05-02
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: "[MSW] ... works full-time. Resident appropriate, tearful at times when discussing prognosis and return to home. Discussed SNF length of ...", "[MD] ...tory maintained. Resident also endorses low mood, poor sleep, and decreased interest in activities since hospitalization — consi..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...room air, transitioned off supplemental oxygen this afternoon per physician order. Lung sounds clearer bilaterally, cough less..."