Transition of Care Summary – Sunrise Clinical Manager Patient Name: Maria Lopez MRN: 00831276 Age: 60 years Admit Date: 10/06/2025 Discharge Date: 10/14/2025 Attending Physician: Dr. Benjamin Carter Case Manager: Rachel Kim, RN, MSN, CCM Admitting Diagnosis: Left Femoral Neck Fracture, s/p Left Hip Hemiarthroplasty Discharge Diagnosis: Same Discharge Destination: Skilled Nursing Facility – Green Valley Post-Acute Center Clinical Summary Patient admitted following a ground-level fall at home resulting in a displaced left femoral neck fracture. Underwent left hip hemiarthroplasty on 10/07/2025. Postoperative course stable. Pain well controlled with oral medications. Tolerating regular diet. Physical Therapy reports moderate assistance required for transfers and ambulation. Medically cleared for discharge to skilled nursing facility for ongoing rehabilitation and strengthening prior to returning home. Functional Status at Discharge Ambulation: 15–25 feet with walker and moderate assistance ADLs: Requires assistance with lower-body dressing and toileting Cognitive: Alert and oriented ×4 Continence: Continent of bowel and bladder Pain: Controlled with oral acetaminophen and oxycodone PRN Medications at Discharge Acetaminophen 650 mg PO q6h PRN pain Oxycodone 5 mg PO q6h PRN severe pain Enoxaparin 40 mg SQ daily ×14 days (DVT prophylaxis) Lisinopril 10 mg PO daily Metformin 500 mg PO BID with meals (Medication Reconciliation completed and verified in SCM; medication list provided in discharge packet.) Discharge Orders / Follow-Up Receiving Facility: Green Valley Post-Acute Center Contact: Admissions Nurse – Sandra Hill, RN Phone: (555) 892-4410 Fax: (555) 892-4412 Receiving Physician: Dr. Mark Thompson (SNF Medical Director) Follow-Up Appointments: Orthopedic Surgeon: 10/29/2025 @ 09:00 Primary Care Physician: Within 1 week after SNF discharge Patient / Family Education Reviewed incision care, activity limitations (no hip flexion >90°, no crossing legs), and use of walker. Discussed pain management and signs of infection. Reinforced anticoagulation precautions while on enoxaparin. Patient and daughter verbalized understanding; teach-back completed. Social / Support Information Lives with adult daughter in one-story home. Daughter provides primary care and transportation. Home setup includes walk-in shower and supportive devices (grab bars, handrail). No financial or insurance barriers identified. Care Coordination Summary Case manager coordinated placement and transfer with Green Valley Post-Acute Center. Insurance authorization approved through UnitedHealthcare, valid 10/14–10/21/2025. Clinical packet (H&P, operative note, MAR, therapy progress notes) faxed to receiving facility. Bed confirmed; transfer via BLS ambulance at 14:30. Bedside nurse notified and report called to receiving RN. Family updated and in agreement with plan. Barriers / Resolutions ☑ Post-acute placement — resolved (bed secured) ☑ Insurance authorization — approved ☐ Transportation — scheduled and confirmed ☐ Medication coverage — no issues reported Outcome Patient stable for discharge and transfer to Green Valley Post-Acute Center for skilled nursing and rehabilitation. All discharge documentation, orders, and education completed. Care coordination finalized and communicated to all involved providers. Signature: Rachel Kim, RN, MSN, CCM Case Manager 10/14/2025 11:50