CARING NURSES, INC.
SOC HHRG
Patient: SHAW, THOMAS- MR# 900010755
Chart: 2 Episode: 1
Patient Care Assistant: LIVE ALONE /DAUGHTER HELPS
Visit Date: 03/12/2026
Problems:
ACUTE UGIB LIKELY PUD FROM NSAID AND ASPIRIN, HEMORRHAGIC SHOCK SECONDARY TO GI BLEED, AFIB WITH RVR, ACUTE BLOOD LOSS ANEMIA,, CAD, COPD, CHF, OXYGEN, CKD STAGE 3, COMPRESSION FRACTURE LUMBAR

Tests
CLOX:
fail

03/12/2026
OASIS-D
Alexis Balle
Assessor
(M0030) Start of Care Date:
03/12/2026

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

(M1033) Therapies the patient receives at home: (Mark all that apply.).
2 - Unintentional weight loss of a total of 10 pounds or more 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:
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).
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.
1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.

(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
03/12/2026
Skilled Nursing Alexis Balle
Added by: Veltra 03/13/26 02:13 PM
1Week1
03/12/26 - 03/13/26
1
2Week1
03/14/26 - 03/20/26
2
1Week8
03/21/26 - 05/10/26
8
Physical Therapy
CONSULT SAFETY TRANSFER AND HEP 1 WK1 		Conrad Chi
Added by: Danielle 03/15/26 12:51 PM
Eval
03/12/26 - 05/10/26
1
Primary Care Physician DR. REBECCA CHURCH
PECOS Enrolled
Physician Scheduled Visit 12/17/2025: DR. SWATI WADHWANI
03/02/2026: DR. ASHER GRIFFITH
Reported to: Veltra 03/13/2026 02:13 PM
Printed By/Date/Time: 04/06/2026 09:06 AM