Hi Jennifer — here's how Margaret is doing
4 visits scheduled this week · Care team has been in touch 3 times in the last 48 hours
Current care episode
Day 12 of 60
Mar 30, 2026 → May 29, 2026 · Primary diagnosis: Congestive heart failure, post-hospitalization
48 days remaining · Recertification review at day 50
Upcoming Visits
Next 7 daysSkilled Nursing Visit
2:00 PM · ~45 min · Maria Gonzalez, RN
PT Session — Balance & Strength
10:30 AM · ~60 min · Sam Nakamura, PT
Medication Management
9:00 AM · ~30 min · James Wu, RN
Home Safety + ADL Assessment
11:00 AM · ~60 min · Rebecca Chen, OT
Care Plan Goals
Stabilize cardiac function
Target: Weight < 158 lbs, no edema
Return to independent ambulation
Target: Walk 50 ft with cane, no assist
Medication independence
Target: Self-administer daily meds with pill organizer
Home safety
Target: Bathroom grab bars, no fall risks
Recent Visit History
Skilled Nursing Visit
Apr 9, 2026 · Maria Gonzalez, RN
Vitals stable. Weight -1.2 lbs since last visit (fluid retention improving). Education on low-sodium diet reinforced with daughter present.
PT Evaluation + Session
Apr 7, 2026 · Sam Nakamura, PT
Progressed to 10-minute walks with rolling walker. Balance improving. Next goal: transition to cane within 2 weeks.
Medication Reconciliation
Apr 4, 2026 · James Wu, RN
Reviewed all medications with client and daughter. Pill organizer set up for next 2 weeks. No side effects reported.
Follow-up Assessment
Apr 2, 2026 · Maria Gonzalez, RN
Wound check (incision site healing well). Lung sounds clear. O2 sat 96% on room air.
Your Care Team
Maria Gonzalez, RN
Case Manager (Primary RN)
Dr. Robert Keane, MD
Medical Director
James Wu, RN
Visiting Nurse
Carlos Rivera, RN
Visiting Nurse (weekends)
Sam Nakamura, PT
Physical Therapist
Rebecca Chen, OT
Occupational Therapist
Messages
Maria Gonzalez, RN
Good news — Mom's weight is down another pound. We'll continue the current plan...
3 hours ago
Sam Nakamura, PT
Reminder: practice the seated exercises we went over on Tuesday...
Yesterday
Liberty Intake Coordinator
Your next month's care plan has been shared. Please review and sign at next visit.
Apr 9
Current Medications
5 activeFurosemide 40mg
Once daily, morning
Diuretic
Metoprolol 50mg
Twice daily
Beta-blocker
Lisinopril 10mg
Once daily
ACE inhibitor
Aspirin 81mg
Once daily
Antiplatelet
Atorvastatin 20mg
Once daily, evening
Statin
Protected health information
You have access to Margaret's PHI as her authorized family caregiver. All access is logged for HIPAA compliance.