Case Management Progress Note – Sunrise Clinical Manager

Patient Name: James Patterson
MRN: 00487933
Age: 60 years
Admit Date: 10/09/2025
Date/Time of Note: 10/14/2025 13:45
Case Manager: Emily Hart, RN, BSN, CCM
Attending Physician: Dr. Michael Chen
Admitting Diagnosis: Status Post Left Total Knee Arthroplasty (Osteoarthritis)

Reason for Admission

Elective left total knee replacement due to chronic pain and functional impairment from osteoarthritis unresponsive to conservative therapy.

Clinical Summary / Current Status

POD #5 (Post-Op Day 5).

Vitals stable, afebrile.

Ambulating 75 feet with rolling walker under PT supervision.

Incision clean, dry, intact; no drainage noted.

Pain managed effectively with oral analgesics.

On anticoagulation (rivaroxaban) for DVT prophylaxis.

Tolerating diet and fluids; normal bowel function resumed.

Cleared by physical therapy for discharge home with home health follow-up.

Living Situation / Social Support

Resides with spouse in a single-level home with one step at entry.

Independent with ADLs prior to admission.

Spouse available for 24-hour assistance.

Bedroom and bathroom on same level; no reported safety concerns.

Discharge Planning Summary

Anticipated Discharge Date: 10/15/2025

Discharge Destination: Home with home health services

Services Arranged:

Home health PT/OT through Valley Home Care (referral sent and accepted)

Nursing follow-up for wound check and medication education

DME Ordered: Rolling walker delivered to bedside; raised toilet seat to be delivered to home

Transportation: Family vehicle

Follow-Up Appointments:

Orthopedic surgeon follow-up: 10/28/2025

Primary care physician: within 2 weeks of discharge

Patient / Family Education

Reviewed wound care instructions, DVT prevention, and medication schedule.

Reinforced use of assistive devices and safety precautions during ambulation.

Discussed pain management plan and signs of complications to report.

Patient and spouse demonstrated understanding using teach-back method.

Barriers / Issues

☐ Home environment — No issues identified
☑ Pain management — Controlled
☐ Insurance/financial — None reported
☐ Psychosocial — None reported

Plan / Next Steps

Confirm home health acceptance and start of care date prior to discharge.

Verify DME delivery to home.

Provide printed discharge packet and medication reconciliation prior to discharge.

Communicate discharge readiness to attending and nursing staff.

Signature:
Emily Hart, RN, BSN, CCM
Case Manager
10/14/2025 13:45