From the intake packet to PDPM capture
One synthetic skilled-nursing admission. Basalt reads the documentation that arrives at intake and surfaces the elements that set the PDPM rate, each one tied back to the line of record it came from.
MEMORIAL REGIONAL HOSPITAL — DISCHARGE SUMMARY
78-year-old female admitted after a mechanical fall with right hip pain. Underwent open reduction internal fixation (ORIF) of the right femoral neck on hospital day 1, tolerated well.
Past medical history: insulin-dependent type 2 diabetes mellitus, hypertension, morbid obesity, BMI 41, osteoarthritis.
Hospital course: On postoperative day 3 the surgical site developed purulent drainage. Wound cultures returned positive for methicillin-resistant Staphylococcus aureus (MRSA). The patient was started on IV vancomycin, to be continued at the receiving facility for a planned 10-day course.
Nutrition: Speech therapy noted intermittent coughing with thin liquids; swallow study showed mild oropharyngeal dysphagia, placed on a mechanically altered (pureed) diet with nectar-thick liquids.
Functional status: requires substantial assistance for bed mobility and transfers; unable to ambulate without two-person assist at discharge.
Disposition: Skilled nursing facility for rehabilitation and IV antibiotic completion.