Transition of Care Handoff Summary

Patient Name: Maria Lopez
MRN: 00831276
Date of Birth: 07/12/1965 (Age 60)
Admit Date: 10/06/2025
Discharge Date: 10/14/2025
Attending Physician: Dr. Benjamin Carter
Case Manager: Rachel Kim, RN, MSN, CCM
Receiving Facility: Green Valley Post-Acute Center
Receiving Provider: Dr. Mark Thompson
Facility Contact: Sandra Hill, RN – Admissions Nurse
Facility Phone: (555) 892-4410
Fax: (555) 892-4412

Reason for Admission

Patient was admitted for management of a displaced left femoral neck fracture sustained in a fall at home. Underwent left hip hemiarthroplasty on 10/07/2025. Postoperative recovery was uncomplicated. Patient is being discharged for continued skilled rehabilitation and strengthening prior to return home.

Hospital Course Summary

Post-surgical recovery was stable. Patient remained afebrile with stable vital signs. Wound clean, dry, intact. Pain adequately managed with oral analgesics. Engaged in daily PT/OT sessions and demonstrated gradual progress. Tolerated a regular diet and maintained good oral intake. Cleared by attending and therapy teams for discharge to skilled nursing facility.

Functional Status at Discharge

Ambulates 15–25 feet with walker and moderate assistance

Requires assistance with dressing and toileting

Cognitively intact, alert, and oriented ×4

Continent of bowel and bladder

Pain controlled on oral regimen

Medications at Discharge
Medication	Dose & Route	Frequency	Indication
Acetaminophen	650 mg PO	q6h PRN	Mild pain
Oxycodone	5 mg PO	q6h PRN	Moderate–severe pain
Enoxaparin	40 mg SQ	Daily ×14 days	DVT prophylaxis
Lisinopril	10 mg PO	Daily	Hypertension
Metformin	500 mg PO	BID with meals	Type 2 Diabetes

(Medication list reconciled and verified. Copies included in transfer packet.)

Follow-Up Appointments

Orthopedic Surgeon (Dr. Benjamin Carter): 10/29/2025 @ 09:00

Primary Care Physician: Within 1 week after SNF discharge

Discharge Instructions

Maintain hip precautions: avoid bending hip >90°, no crossing legs, and avoid twisting.

Use walker for all ambulation.

Keep incision clean and dry; report redness, drainage, or increased pain.

Continue enoxaparin for 14 days.

Monitor for signs of infection or blood clots.

Maintain adequate hydration and high-protein diet for healing.

Social / Support Information

Resides with adult daughter in single-story home.

Daughter provides primary care, transportation, and assistance with ADLs.

Home equipped with grab bars and shower seat.

Patient and family educated on recovery plan and demonstrate understanding.

Transfer Details

Destination: Green Valley Post-Acute Center

Transport: BLS ambulance (MedTrans) – pickup 14:30

Insurance: UnitedHealthcare – SNF authorization approved (valid 10/14–10/21/2025)

Documents Sent: H&P, operative note, MAR, therapy notes, discharge summary, and medication list

Report Given To: Sandra Hill, RN at Green Valley Post-Acute

Summary Statement

Maria Lopez is medically stable for transfer to Green Valley Post-Acute Center for continued skilled nursing and rehabilitation following left hip hemiarthroplasty. All discharge planning and education completed. Family informed and in agreement with plan.

Prepared By:
Rachel Kim, RN, MSN, CCM
Case Manager – Hospital Case Management Department
Date: 10/14/2025