Case Management Progress Note

Date/Time: 10/14/2025 11:30
Case Manager: Dana Reynolds, RN, BSN, CCM
Patient: Karen Mitchell, MRN 00562178
Age: 60 years
Admit Date: 10/10/2025
Diagnosis: Status post total hip arthroplasty (right); Osteoarthritis of right hip

Admission Reason:
Elective right total hip replacement due to progressive osteoarthritis and functional decline.

Current Status / Clinical Update:

POD #4 (Post-Op Day 4).

Vitals stable; afebrile.

Ambulating with front-wheeled walker under PT supervision.

Incision clean, dry, intact; dressing changed this morning.

Pain controlled with oral medication.

Tolerating diet; bowel function resumed.

Anticoagulation therapy initiated per post-op protocol.

Living Situation / Support:

Resides with spouse in single-level home with two steps to entry.

Independent with ADLs prior to surgery.

Spouse available full-time for assistance.

Bedroom and bathroom accessible on main floor.

Discharge Planning:

Anticipated discharge: 10/15/2025 (pending PT clearance).

PT/OT recommend home health for continued mobility and safety training.

Referral sent to Sunrise Home Health; acceptance confirmed.

Durable Medical Equipment: Front-wheeled walker and raised toilet seat arranged through MedEquip.

Follow-up appointment with orthopedic surgeon scheduled for 10/28/2025.

Discharge instructions to include wound care, anticoagulation precautions, and signs of infection.

Barriers to Discharge:
☑ Pain management – improving
☑ Mobility – progressing with PT
☐ Home safety – reviewed, no hazards identified
☐ Transportation – family will provide
☐ Insurance/financial – no issues reported

Education Provided:

Reviewed mobility precautions and safe use of assistive device.

Reinforced importance of home exercise and adherence to PT plan.

Discussed infection prevention and when to contact provider.

Patient and spouse verbalized understanding; teach-back method used.

Plan / Next Steps:

Confirm DME delivery to home prior to discharge.

Complete home health orders and discharge summary.

Provide printed discharge instructions and medication list at bedside.

Continue to monitor for readiness for discharge and coordinate with PT/OT and attending surgeon.

Signature:
Dana Reynolds, RN, BSN, CCM
Hospital Case Manager