CARING NURSES, INC.
SOC HHRG
Patient: NAULT, JASON- MR# 900003707
Chart: 4 Episode: 1
Patient Care Assistant: mother is assisting with care.
Visit Date: 09/10/2024
Problems:
MRSA, IV Abx, UTI, Chronic anoxic encephalopathy, HTN, GERD, Hypoxia, O2 at night, Tube feeding

Tests
CLOX:
fail

09/10/2024
OASIS-D
Joan Leyderos
Assessor
(M0030) Start of Care Date:
09/10/2024

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

(M1033) Therapies the patient receives at home: (Mark all that apply.).
5 - Decline in mental, emotional, or behavioral status 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?
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:
2 - One to three 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?
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.
5 - Bedfast, unable to transfer and is unable to turn and position 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
09/10/2024
Skilled Nursing Joan Leyderos
Added by: Ron 09/10/24 04:10 PM
1Week1
09/10/24 - 09/13/24
1
2Week1
09/14/24 - 09/20/24
2
1Week7
09/21/24 - 11/08/24
7
PRN
09/10/24 - 11/08/24
2
Primary Care Physician DR. JUSTIN TERRY
PECOS Enrolled
Physician Scheduled Visit 08/29/2019: DR. BRIAN LIPMAN
06/29/2020: DR. JUSTIN TERRY
Reported to: Ron 09/10/2024 04:10 PM
Printed By/Date/Time: 09/19/2024 02:08 AM