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Social Work Case Manager Assessment

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I attached the therapy notes on Ms. McMahan from May 23rd and 24th. I did not see any current notes for June. She continues to be nonbearing and transfer from bed to chair with a total lift. The following is the RN Case Manager assessment on 06.15.2017:

Pt was observed sitting in her w/c in her room at Victoria Gardens Rehab. She is alert and oriented to self, family, and familiar faces. She speaks limited words and is very forgetful. She had trouble remembering her DOB, President. She denied being in any pain and was not displaying any non verbal signs indicating the presence of pain/discomfort. Her Foley catheter has yellow colored urine w/ sediment and a small blood clot draining. 3+Edema is present in her bilateral legs below
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