Nursing progress note — Day 10 post-admission. Resident continues rehabilitation following cerebral infarction. Vitals today: BP 138/84, HR 74, Temp 98.1°F, SpO2 97% on room air. Resident consumed approximately 65% of pureed lunch with nectar-thick liquids; no coughing or choking observed during meal. Right-sided weakness persists; resident now tolerating moderate assist of 2 for bed-to-chair transfer per PT progress. Mood improved compared to admission; resident smiled during activity participation per CNA report. Sacral pressure injury reviewed: wound now measures 3.5 cm x 2.5 cm, pink granulating tissue present, no signs of infection. Resident repositioned every 2 hours per turning schedule. Compression-reducing mattress overlay in use. Family continues to visit daily and reports satisfaction with care. Will continue to monitor and document.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-04
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 2026-04-04
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
ISOLATIONhigh
Notes describe isolation/precautions. Confirm CDC isolation criteria and capture O0100M for nursing classification (Extensive Services tier).
Field: O0100M
Evidence: "[MD] ...in context of new disability and social isolation. Will monitor closely over next week. Medication reconciliation reviewed and co..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...s today: BP 138/84, HR 74, Temp 98.1°F, SpO2 97% on room air. Resident consumed approximately 65% of pureed lunch with necta...", "[RN] ...: BP 148/88, HR 76, RR 16, Temp 97.9°F, SpO2 96% on room air. Alert and oriented x2 (person, place); word-finding difficulty..."