BID dressing change to sacral wound. Purulent drainage with foul odor, increased volume since last shift. Surrounding tissue erythematous and warm to touch. Wound culture sent. Notified Dr. Chen — started IV cefazolin 1g q8h. Patient afebrile, T 99.1.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-04
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 2026-03-04
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
WOUND INFECTIONmedium
Notes describe wound infection. Capture MDS I2500 (Wound Infection Code) — drives NTA component +2 points per CMS PDPM NTA fact sheet.