Nursing progress note — Day 10. Mr. Bridges tolerating oral antibiotic course well; no GI complaints reported. Respiratory status improving — weaned to room air with SpO2 maintaining 95–97% at rest. Cough now intermittent and non-productive. Appetite improved per CNA report; consuming approximately 75% of meals on modified diet per SLP recommendation. During routine skin assessment, a 2.0 cm x 1.5 cm area of partial-thickness skin loss with pink wound bed identified on coccyx, consistent with Stage 2 pressure injury. Area noted to be new since last full skin check on 04/10. Physician notified. Resident repositioned and pressure-relieving mattress overlay requested. Resident and daughter informed of skin finding. Resident continues to participate in therapy with reported improvement in mobility per therapy team.
MDS 3.0 · Section I — Active Diagnoses · target 2026-04-18
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 2026-04-18
O0100H2IV Medications Post-admit···☐ NOT CODED
O0100M2Isolation/Precautions···✓
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: "[MD] ...d sensitivity results. Resident reports low mood, poor appetite, and diminished interest in activities since hospitalization. Fa..."
OXYGENmedium
Notes describe supplemental oxygen. Capture O0100C (oxygen) at next MDS — drives Special Care High nursing classification.
Field: O0100C
Evidence: "[RN] ...tus improving — weaned to room air with SpO2 maintaining 95–97% at rest. Cough now intermittent and non-productive. Appetite...", "[LPN] ...st-fall: T 98.4°F, HR 88, BP 142/84, no SpO2 change. No visible injuries noted; resident ambulatory back to bed with max ass..."