CARING NURSES, INC.
SOC HHRG
Patient: COBOS, VERA- MR# 900009468
Chart: 2 Episode: 1
Patient Care Assistant: DAUGHTER
Visit Date: 09/03/2024
Problems:
DISPLACED FRACTURE OF BASE OF NECK OF RIGHT FEMUR SUBSEQUENT, DISORDER OF BONE UNSPECIFIED, RECENT UTI, COPD, OXYGEN, UNSPECIFIED DEMENTIA, DEPRESSION, HTN, HX CONSTIPATION, REPEATED FALLS,, PRESNECE OF RIGHT ARTIFICIAL HIP JOINT

Tests
CLOX:
fail

09/03/2024
OASIS-D
Soline Louis
Assessor
(M0030) Start of Care Date:
09/03/2024

(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:
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).
2 - Someone must assist the patient to groom self.

(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).
3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.

(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
2 - Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).

(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.
3 - Able to walk only with the supervision or assistance of another person at all times.

(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
09/03/2024
Skilled Nursing Soline Louis
Added by: Veltra 09/03/24 04:35 PM
2Week1
09/03/24 - 09/06/24
2
1Week8
09/07/24 - 11/01/24
8
Physical Therapy
CONSULT SAFETY, TRANSFER AND HEP RECENT FALLS 1 WK 2 will seen the week 09/07/24 		Conrad Chi
Added by: Julia 09/05/24 02:17 PM
Eval
09/03/24 - 11/01/24
1
Primary Care Physician DR. STANLEY KIDIAVAYI
PECOS Enrolled
Physician Scheduled Visit 07/27/2024: DR. ROSE LEIH JUSAYAN
Reported to: Veltra 09/03/2024 04:35 PM
Printed By/Date/Time: 09/19/2024 02:12 AM