No weight, no comparison, no congestion detail, no GDMT tolerance, no skilled rationale.
The HF-recovery model note in §3: weight vs prior/target, congestion signs, GDMT tolerance against parameters, and the reason daily skilled observation was required.
“Lasix given.”
No weight/edema trigger, no response, no MDS support.
“4-lb gain and new 3+ edema with crackles/JVD → parameter-based diuretic per order → relief after voiding; provider notified; reassess next shift.”
“BP low, dose held.”
No value, no parameter, no notification, no reassessment.
“BP 92/54 with lightheadedness after the beta-blocker → held per parameters → provider notified; dose adjustment ordered; reassess vitals next shift.”
