CARING NURSES, INC.
SOC HHRG
Patient: CLAIBORNE, PAULINE- MR# 900009579
Chart: 1 Episode: 1
Patient Care Assistant: HUSBAND
Visit Date: 08/31/2024
Problems:
LEFT FOOT DROP, ACUTE HYPOXIC RESPIRATORY FAILURE, IV ABT, LT FOREARM MIDLINE, S/P COFLEX IMPLANTATION WITH RECURRENT STENOSIS, HTN, HLD, HYPOTHYROIDISM, MODERATE PROTEIN CALORIE MALNUTRITION, ACUTE HYPOXIC RESPIRATORY FAILURE

Tests
CLOX:
fail

08/31/2024
OASIS-D
Jeanne Javinar
Assessor
(M0030) Start of Care Date:
08/31/2024

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

(M1033) Therapies the patient receives at home: (Mark all that apply.).
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

(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?
2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)

(M1610) Urinary Incontinence or Urinary Catheter Presence:
2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]

(M1620) Bowel Incontinence Frequency:
4 - On a daily basis

(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?
0 - Patient does not have an ostomy for bowel elimination.
(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.
6 - Bedfast, unable to ambulate or be up in a chair.

(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.
NA - No injectable medications prescribed.

Home Health Certification and Plan of Care
08/31/2024
Skilled Nursing Jeanne Javinar
Added by: Veltra 09/02/24 04:09 PM
Veltra Metts-Cannon
Added by: Veltra 09/04/24 11:14 AM
2Week1
08/31/24 - 09/06/24
2
1Week8
09/07/24 - 10/29/24
8
PRN
08/31/24 - 10/29/24
2
Primary Care Physician DR. STANLEY KIDIAVAYI
PECOS Enrolled
Reported to: Veltra 09/02/2024 04:09 PM
Printed By/Date/Time: 09/19/2024 02:16 AM