End-of-week nursing progress note, day 14. Ms. Chen remains medically stable. Vitals today: BP 138/80, HR 76, RR 16, Temp 98.6°F, SpO2 97% RA. Appetite improved; consuming approximately 80% of meals on modified diet as ordered by SLP. Bowel and bladder: continent with scheduled toileting program in place. Skin: coccyx wound re-assessed; wound measures 3.5 cm x 2.5 cm, appears to be granulating, no signs of infection. Resident increasingly interactive; using communication board appropriately and initiating eye contact with staff. Mood appears improved from admission. Sleep reported as adequate by CNA on night shift. Left hemiparesis persists; continues on fall prevention protocol. Family visited daily this week; daughter reports satisfaction with care. Skilled level of care continues to be supported by therapy and nursing needs. No acute concerns at this time.
MDS 3.0 · Section I — Active Diagnoses · target 2026-03-31
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 2026-03-31
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
ISOLATIONhigh
Notes describe isolation/precautions. Confirm CDC isolation criteria and capture O0100M for nursing classification (Extensive Services tier).
Field: O0100M
Evidence: "[MSW] ...d as part of discharge planning. Social isolation a concern given communication barriers and language needs. Referral placed for ..."