CARING NURSES, INC.
SOC HHRG
Patient: STORY, JOYCE- MR# 900002325
Chart: 2 Episode: 1
Patient Care Assistant: daughter
Visit Date: 05/22/2025
Problems:
GENERALIZED WEAKNESS, IMPAIRED PHYSICAL MORBIDITY, DEPRESSION, ATAXIA, HX OF CERVICAL FUSION, NEUROPATHIC PAIN, SJOGREN'S SYNDROME, DISCOID LUPUS, HYPOTHYROIDISM

Tests
CLOX:
pass

05/22/2025
OASIS-D
Soline Louis
Assessor
(M0030) Start of Care Date:
05/22/2025

(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?
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:
1 - Patient is incontinent

(M1620) Bowel Incontinence Frequency:
0 - Very rarely or never has bowel incontinence

(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:
2 - Someone must help the patient put on upper body clothing.

(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
05/22/2025
Skilled Nursing Soline Louis
Added by: Veltra 05/22/25 05:33 PM
1Day4
05/22/25 - 05/25/25
4
1Day Q 3Weeks X 8Weeks
05/26/25 - 07/18/25
3
1Day4
05/22/25 - 05/25/25
4
1Day4
06/12/25 - 06/15/25
4
1Day4
07/03/25 - 07/06/25
4
1Week2
07/07/25 - 07/18/25
2
PRN
05/22/25 - 07/20/25
2
Physical Therapy
CONSULT SAFETY ,TRANSFER AND HEP 1 WK 2 Pt won't be seen mid week of next due Holiday 		Annie Copeland
Added by: Veltra 05/23/25 03:20 PM
Eval
05/22/25 - 07/20/25
1
Primary Care Physician DR. SHIRLEY RODRIGUEZ
PECOS Enrolled
Physician Scheduled Visit 04/17/2018: DR. ELIZABETH BROWN
06/19/2018: DR. ELIZABETH BROWN
01/26/2019: DR. DONIELLE FREEDMAN
Reported to: Veltra 05/22/2025 05:33 PM
Printed By/Date/Time: 07/06/2025 04:51 PM