Discharge Coordination Note – Sunrise Clinical Manager Patient Name: Karen Douglas MRN: 00675492 Age: 60 years Admit Date: 10/08/2025 Discharge Date: 10/14/2025 Attending Physician: Dr. Andrew Lee Case Manager: Monica Rivera, RN, BSN, CCM Admitting Diagnosis: Status Post Laparoscopic Cholecystectomy (Gallstones) Discharge Diagnosis: Same Clinical Summary Patient admitted for elective laparoscopic cholecystectomy due to recurrent symptomatic cholelithiasis. Postoperative course uncomplicated. Pain controlled with oral analgesics. Diet advanced to regular and tolerated well. Ambulating independently. Vital signs stable. Cleared by attending and surgical team for discharge home today. Discharge Disposition Destination: Home with family Transportation: Spouse will drive patient home Support System: Lives with spouse; adult children nearby and available as needed Functional Status at Discharge: Ambulating independently, performing ADLs with minimal assistance Home Care / Post-Discharge Services Home Health: Not indicated Durable Medical Equipment (DME): None required Follow-Up Appointments: Surgeon (Dr. Andrew Lee): 10/28/2025 at 10:00 AM Primary Care Provider: Within 2 weeks as needed Prescriptions: Sent electronically to CVS Pharmacy, Main Street Education / Instructions Provided Reviewed wound care instructions; patient to keep incision clean and dry, may shower in 24 hours. Discussed diet progression and activity limitations (no lifting >10 lbs for 2 weeks). Reviewed pain management plan and signs/symptoms of infection. Provided written discharge instructions and confirmed patient understanding using teach-back method. Encouraged to contact surgeon’s office for any fever >101°F, drainage, redness, or increasing pain. Barriers to Discharge ☐ Clinical instability — none ☐ Home safety — no concerns identified ☐ Financial/insurance — no issues reported ☐ Transportation — arranged ☑ Patient readiness — confirmed Care Coordination Activities Verified discharge orders with attending provider. Communicated discharge plan with bedside nurse. Confirmed follow-up appointments and verified patient understanding. Updated care team in SCM regarding discharge disposition and education completion. Case management notified unit clerk and care coordinator of discharge. Final Plan / Outcome All discharge needs addressed. Patient medically stable for discharge home with family support. No additional post-acute care services required. Case management services completed. Signature: Monica Rivera, RN, BSN, CCM Case Manager 10/14/2025 10:25