Case Management Progress Note

Date/Time: 10/14/2025 09:45
Case Manager: Sarah Thompson, RN, BSN, CCM
Patient: John Doe, MRN 00456231
Admit Date: 10/10/2025
Diagnosis: Community-Acquired Pneumonia; Type 2 Diabetes Mellitus

Reason for Admission:
Admitted from ED with fever, cough, and shortness of breath. Chest X-ray confirmed left lower lobe pneumonia.

Current Status:

Patient remains on 2L O₂ via nasal cannula, SpO₂ 95%.

Ambulating with assistance.

Blood glucose remains elevated but improving with insulin correctional scale.

ID and pulmonary consulted; antibiotic therapy transitioned from IV ceftriaxone to oral azithromycin per attending.

Discharge anticipated within 1–2 days pending clinical improvement.

Psychosocial / Support:

Lives alone in single-story home; independent with ADLs prior to admission.

Son (primary contact) lives nearby and assists with transportation and grocery needs.

No current home health services in place.

Patient expresses mild anxiety about returning home alone.

Discharge Planning:

Discussed discharge options with patient and son.

Patient agreeable to short-term home health for medication management and follow-up nursing assessment.

Referral placed to ABC Home Health Agency; acceptance confirmed pending discharge date.

Follow-up appointment with PCP scheduled for 10/21/2025.

Education provided on pneumonia management, inhaler use, and diabetic diet. Patient verbalized understanding.

Barriers to Discharge:

Mild deconditioning.

Requires completion of oral antibiotic course and stable blood glucose prior to discharge.

Plan / Next Steps:

Continue to monitor readiness for discharge.

Confirm home health start date prior to discharge.

Provide printed discharge instructions and reinforce medication education at bedside prior to discharge.

Signature:
Sarah Thompson, RN, BSN, CCM
Case Manager