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Margaret Chen
James Washington
Rosa Martinez
Jerome Okafor
David Leblanc
Amelia Santos
⚠️ Leadership
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📋 Weekly Report
Patients ▸ Margaret Chen
Elena Vasquez, CN · Unit 5N
Margaret Chen
72 y/o Female · Unit 5N, Room 412 · Attending: Dr. Rajesh Patel
● T1: MOVE NOW
82
READINESS
DRG
470 — Major Hip/Knee
Insurance
BCBS MA PPO
LOS / GMLOS
Day 4 / 5.2
Disposition
SNF
Days Under
−1.2
Clinical Context
Pulled from Epic via FHIR · Updated 6:42 AM
Medical Clearance
Afebrile 48 hrs · WBC 8.2 (↓ from 14.1)
Vitals stable. No vasopressors. PO tolerating.
Vitals last charted: today 0600
Latest Progress Note
Dr. Patel (4/7 AM): "Medically stable for SNF. Completed IV Vancomycin course 4/5. Transitioned to PO Augmentin. Cleared for discharge when placement confirmed."
Epic note ID: 2026-0407-PN-1842
Therapy Status
PT: Cleared for SNF-level (eval 4/5)
OT: Cleared — recommends continued rehab at SNF
Functional: Amb 50ft with walker, mod assist
Medications
IV → PO transition: Complete
Active: Augmentin PO 875mg BID (started 4/5)
Enoxaparin 40mg SQ daily (DVT prophylaxis)
No IV meds — SNF compatible
Orders — Discharge Relevant
Echo: Completed 4/6 — EF 55%, no concerns
PT eval: Completed 4/5
Wound care consult: Completed 4/4
No pending orders blocking discharge
Insurance Authorization
BCBS MA: Authorized
Auth# BC-2026-0847 · Expires 4/14
SNF days approved: 20
Barrier Summary
Patient medically cleared. Insurance authorized. Family aligned. Needs accepting SNF facility and transport coordination.
Navigator AI Actions
✓
Verify BCBS MA auth — confirmed #BC-2026-0847
✓
PT/OT clearance obtained — SNF-level
✓
Family meeting — Linda aligned with SNF plan
Send SNF referrals — 3 facilities identified
Arrange medical transport
Confirm DME walker delivery to SNF
Send placement options to family
SNF Referral Workflow
3 facilities matched on bed availability, BCBS MA acceptance, distance, and service fit.
Brookhaven Skilled Nursing
4.2 mi · BCBS MA · PT/OT · Wound care
Bed available — private room, admit April 8 at 10 AM
SENDING
Meadowview Rehabilitation
6.8 mi · BCBS MA · Wound care specialty
No beds until April 14
SENDING
Worcester Rehab Center
2.1 mi · BCBS MA · PT/OT + wound care
Bed available — semi-private, admit April 10 at 2 PM
SENDING
Key Contacts
RP
Dr. Rajesh Patel
Attending Physician
(508) 334-1000
LC
Linda Chen
Daughter — Healthcare POA
(508) 555-0188
JM
Janet Miller
PT/OT Lead
x4521
DR
Donna Reilly
Admissions · Brookhaven SNF
(508) 555-0147
Discharge Checklist
✓
Medical clearance confirmed
✓
Insurance authorization obtained
✓
PT/OT eval completed
✓
Family meeting completed
✓
IV → PO medication transition
SNF acceptance confirmed
Transport arranged
DME delivered to facility
Discharge order placed
Discharge summary to PCP
Patient Preferences
Location: Within 10 mi of Worcester (01602)
Room: Private preferred
Family: Daughter Linda — primary decision-maker, visits daily
Language: English
Diet: Low sodium
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