CARING NURSES, INC.
SOC HHRG
Patient: JONES, GOVANNA- MR# 900009567
Chart: 1 Episode: 1
Patient Care Assistant:
Visit Date: 08/28/2024
Problems:
PHLEGMON VS ABSCESS LEFT PERIGLUTEAL REGION 5.2 X 3 CM,, WOUND CARE, UTI ON PO ABT, HTN, OXYGEN PRN AT HS, WHEELCHAIR BOUND, OBESITY, WOUND LEFT LOWER LEG, HX OF TIA, HX OF CVA,

Tests
CLOX:
fail

08/28/2024
OASIS-D
Iwona Arusztowicz
Assessor
(M0030) Start of Care Date:
08/28/2024

(M1030) Therapies the patient receives at home: (Mark all that apply.)

(M1033) Therapies the patient receives at home: (Mark all that apply.).
1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months)
3 - Multiple hospitalizations (2 or more) in the past 6 months
4 - Multiple emergency department visits (2 or more) in the past 6 months
5 - Decline in mental, emotional, or behavioral status in the past 3 months
6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
7 - Currently taking 5 or more medications
8 - Currently reports exhaustion

(M1200) Vision (with corrective lenses if the patient usually wears them):

(M1242) Frequency of Pain Interfering with patient's activity or movement:

(M1400) When is the patient dyspneic or noticeably Short of Breath?
3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation

(M1610) Urinary Incontinence or Urinary Catheter Presence:
1 - Patient is incontinent

(M1620) Bowel Incontinence Frequency:
3 - Four to six times weekly

(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
(M1800). Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
3 - Patient depends entirely upon someone else for grooming needs.

(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
3 - Patient depends entirely upon another person to dress the upper body.

(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:
3 - Patient depends entirely upon another person to dress lower body.

(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
6 - Unable to participate effectively in bathing and is bathed totally by another person.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
4 - Is totally dependent in toileting.

(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
2 - Able to bear weight and pivot during the transfer process but unable to transfer self.

(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
4 - Chairfast, unable to ambulate but is able to wheel self independently.

(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
3 - Unable to take injectable medication unless administered by another person.

Home Health Certification and Plan of Care
08/28/2024
Skilled Nursing Iwona Arusztowicz
Added by: Veltra 08/29/24 02:39 PM
1Week1
08/28/24 - 08/30/24
1
2Week2
08/31/24 - 09/13/24
4
1Week7
09/14/24 - 10/26/24
7
PRN
08/28/24 - 10/26/24
2
Physical Therapy
CONSULT SAFETY, TRANSFER, HEP 1 WK 1 		Joseph Tanaquin
Added by: Veltra 08/29/24 03:40 PM
Eval
08/28/24 - 10/26/24
1
Primary Care Physician DR. STANLEY KIDIAVAYI
PECOS Enrolled
Reported to: Veltra 08/29/2024 02:39 PM
Printed By/Date/Time: 09/19/2024 02:11 AM