CARING NURSES, INC.
SOC HHRG
Patient: MARTINEZ, JUBENTINO- MR# 900003164
Chart: 14 Episode: 1
Patient Care Assistant: grandson is assisting with care.
Visit Date: 09/10/2024
Problems:
Cellulitis, Left above knee amputation, HTN, DM2, PE on eliquis, AFIB, CHF, Foley catheter

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.).
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
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?
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).
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.
3 - Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.

(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
4 - Bedfast, unable to transfer but is able to turn and position self in bed.

(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.
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 04:46 PM
2Week1
09/10/24 - 09/13/24
2
1Week8
09/14/24 - 11/08/24
8
PRN
09/10/24 - 11/08/24
2
Home Health Aide
1/WK X 4WKS 		Marietta Salvani
Added by: Ragna 09/11/24 01:14 PM
1Week4
09/10/24 - 10/04/24
4
Primary Care Physician DR. SCOTT LAMPRECHT
PECOS Enrolled
Physician Scheduled Visit 01/09/2019: DR. MELISSA MOYER
01/09/2019: DR. DONIELLE FREEDMAN
04/09/2019: DR. DONIELLE FREEDMAN
04/23/2019: DR. MELISSA MOYER
09/29/2020: DR. SCOTT LAMPRECHT
03/02/2021: DR. SCOTT LAMPRECHT
06/13/2021: DR. SCOTT LAMPRECHT
03/08/2022: DR. SCOTT LAMPRECHT
06/29/2022: DR. SHIVEN CHAUDHRY
12/10/2022: DR. JENNIFER REED
09/09/2023: DR. SCOTT LAMPRECHT
09/26/2023: DR. HOSSEIN AKHONDI ASL
04/14/2024: DR. TALHA JILANI
Reported to: Ron 09/10/2024 04:46 PM
Printed By/Date/Time: 09/19/2024 02:10 AM