Document the HF-specific skilled surveillance and management each day:
Daily weight against the prior value and the dry-weight/target, with the trend; edema (location and grade) and its change.
Congestion signs: lung sounds (bibasilar crackles), jugular venous distension, a new S3, orthopnea/paroxysmal nocturnal dyspnea, and exertional dyspnea.
GDMT tolerance (blood pressure and heart rate against parameters, renal function and potassium from labs) and the diuretic response; sodium and fluid adherence.
MDS-supportive data
Cardiac medication and anticoagulant days are coded in MDS Section N, weight in Section K, IV medication in Section O, dyspnea/edema in Section J, and the HF diagnosis in Section I. The record must document the daily weight, the medication response, and the congestion assessment so the MDS is supported.
