Home Health Agency Communication Cover Sheet

To: Valley Home Care
Fax: (555) 456-7722
Phone: (555) 456-7721
Attention: Intake / Admissions Nurse

From: Hospital Case Management
Fax: (555) 987-1234
Phone: (555) 987-5678
Case Manager: Thomas Gray, RN, BSN, CCM

Patient Name: Daniel Reed
MRN: 00911457
DOB: 03/22/1965 (Age 60)
Admit Date: 10/09/2025
Discharge Date: 10/14/2025

Reason for Referral / Discharge

Cellulitis of right lower leg, resolved with IV and oral antibiotics

Type 2 Diabetes Mellitus, ongoing management

Patient requires skilled nursing and PT for post-discharge follow-up

Home Health Orders

Skilled Nursing:

Wound assessment, dressing changes, infection monitoring

Medication review and education

Glucose monitoring

Physical Therapy:

Strengthening and mobility training

Fall prevention education

Education:

Diabetes self-management reinforcement

Antibiotic adherence

Wound care teaching

Medications (Key at Discharge)
Medication	Dose	Frequency
Cephalexin	500 mg PO	q6h ×7 days
Insulin glargine	20 units SQ	HS
Metformin	1000 mg PO	BID
Lisinopril	10 mg PO	Daily
Acetaminophen	650 mg PO	q6h PRN

(Full reconciled medication list included in packet.)

Follow-Up / Appointments

Primary Care: 10/21/2025 @ 09:30

Endocrinology: 10/30/2025 @ 13:00

Wound Care Clinic: PRN per home health nurse assessment

Contact / Coordination

Hospital Case Manager: Thomas Gray, RN, BSN, CCM – (555) 987-5678

Attending Physician: Dr. Alicia Nguyen – (555) 987-1122

Family Contact: Spouse – Jane Reed, (555) 234-5566

Patient Condition at Discharge: Medically stable, alert and oriented, able to participate in care with assistance for wound care

Packet Contents (Attached)

☑ Transition of Care Handoff Summary
☑ Medication List / MAR
☑ Discharge Summary
☑ Lab Reports / Imaging (if relevant)
☑ Therapy Notes / PT-OT Progress

Signature / Prepared By:
Thomas Gray, RN, BSN, CCM
Hospital Case Manager
Date: 10/14/2025