Transition of Care Handoff Summary – Home Health Services Patient Name: Daniel Reed MRN: 00911457 Date of Birth: 03/22/1965 (Age 60) Admit Date: 10/09/2025 Discharge Date: 10/14/2025 Attending Physician: Dr. Alicia Nguyen Case Manager: Thomas Gray, RN, BSN, CCM Admitting Diagnosis: Cellulitis of Right Lower Leg Discharge Diagnosis: Resolved Cellulitis, Type 2 Diabetes Mellitus Discharge Destination: Home with Home Health Services Reason for Admission Patient admitted with right lower leg cellulitis and uncontrolled blood glucose. Treated with IV antibiotics and diabetic management. Condition improved with IV cefazolin, transitioned to oral cephalexin prior to discharge. Blood glucose now controlled on insulin and oral medications. Hospital Course Summary During hospitalization, patient received IV antibiotic therapy, wound care, and diabetic education. No evidence of systemic infection at discharge. Wound site shows decreased redness and swelling. Patient independent in self-care and ambulation but requires ongoing wound assessment and diabetic monitoring. Cleared for discharge by hospitalist team. Functional Status at Discharge Ambulates independently without assistive device Performs ADLs independently Cognitively intact and able to follow instructions Requires reinforcement for medication and wound care adherence Home Health Orders Agency: Valley Home Care Phone: (555) 456-7721 Fax: (555) 456-7722 Disciplines Ordered: ☑ Skilled Nursing – wound assessment, dressing changes, education on infection prevention ☑ Physical Therapy – mobility strengthening, fall prevention ☑ Diabetes Education – blood glucose monitoring and dietary counseling Medications at Discharge Medication Dose & Route Frequency Indication Cephalexin 500 mg PO q6h ×7 days Cellulitis Insulin glargine 20 units SQ HS Diabetes Metformin 1000 mg PO BID with meals Diabetes Lisinopril 10 mg PO Daily Hypertension Acetaminophen 650 mg PO q6h PRN Pain/fever (Medication list reconciled and verified; copy sent to home health agency.) Wound / Incision Care Instructions Location: Right lower leg, anterior shin Current dressing: Non-adherent gauze with dry wrap Change dressing once daily and as needed for drainage Clean with normal saline; apply thin layer of mupirocin ointment before dressing Monitor for redness, drainage, swelling, or fever ≥101°F Notify provider or home health nurse if signs of infection occur Follow-Up Appointments Primary Care Physician (Dr. Alicia Nguyen): 10/21/2025 @ 09:30 Endocrinology (Dr. Patel): 10/30/2025 @ 13:00 Wound Care Clinic: As needed, per home health nurse recommendation Patient / Family Education Reviewed diabetic diet and glucose monitoring techniques. Reinforced importance of completing full antibiotic course. Taught wound dressing procedure and infection warning signs. Reviewed insulin administration using teach-back; patient demonstrated correctly. Family (spouse) present and verbalized understanding of care plan. Social / Support Information Lives with spouse in single-level home. Spouse assists with meals, medication setup, and transportation. Home environment safe, with no fall hazards noted. No financial or insurance barriers reported. Transfer / Communication Summary Referral and face-to-face certification completed in SCM and faxed to Valley Home Care. Medication list, discharge summary, and wound photos (secure upload) sent to home health agency. Contact information for discharging physician and case manager included in packet. Patient and spouse provided copies of instructions and home health contact information. Summary Statement Daniel Reed is medically stable for discharge home with skilled home health services for wound monitoring, continued diabetic management, and reinforcement of self-care education. All discharge orders and education completed. Family and home health agency notified and in agreement with plan. Prepared By: Thomas Gray, RN, BSN, CCM Hospital Case Manager Date: 10/14/2025