Case Management Progress Note

Date/Time: 10/14/2025 14:10
Case Manager: Linda Perez, RN, MSN, CCM
Patient: Robert Williams, MRN 00783912
Age: 60 years
Admit Date: 10/09/2025
Diagnosis: Congestive Heart Failure Exacerbation; Hypertension

Progress Note:
Met with patient at bedside this afternoon to discuss discharge planning and support needs. Mr. Williams is a 60-year-old male admitted five days ago for shortness of breath and lower extremity edema secondary to CHF exacerbation. He reports feeling improved today, with less swelling and easier breathing. The patient is currently ambulating short distances in the hallway with standby assist and remains on 1L oxygen as needed.

Mr. Williams lives with his wife in a one-story home and was independent in activities of daily living prior to admission. His wife is retired and able to assist with care at home. They have reliable transportation and access to a nearby pharmacy. The patient follows with a cardiologist at Valley Heart Clinic and has a primary care physician in the same network.

Discussed importance of daily weight monitoring, low-sodium diet, and medication adherence. Patient verbalized understanding and stated he sometimes forgets his evening medications. Education provided on use of a pill organizer and written schedule; patient and spouse both receptive.

Discharge is anticipated for tomorrow pending continued clinical stability and cardiology clearance. Case manager discussed home health nursing for medication reinforcement and weight monitoring. Patient agreeable, and referral was sent to HomeCare Plus; agency confirmed acceptance. Follow-up cardiology appointment arranged for 10/20/2025.

No financial or insurance barriers identified. Patient and spouse appear engaged and motivated to manage his condition at home. Case management will continue to follow for discharge coordination and ensure home health orders are completed.

Signature:
Linda Perez, RN, MSN, CCM
Hospital Case Manager