Nursing Home to Personal Health Record

Personal Health Communication

Patient, SNF Providers, Personal physicians and consultants

Mrs. J is a 72 year old woman admitted to the SNF following a slip and fall accident in her home. She suffered a fracture of her L ankle and had an ORIF procedure performed at the hospital immediately prior to her admission to the SNF.

Upon admission, Mrs. J. is noted to have a history of avascular necrosis of the L hip with chronic hip and back pain, pulmonary fibrosis, fatigue, shortness of breath, instability of lumbar spine, arthritis and peripheral neuropathy.

Mrs. J. remained at the SNF for three weeks during which time she was involved in extensive physical and occupational therapy. Prior to her accident she was - ambulating with a walker, independent with personal hygiene, was occasionally incontinent of bladder and required the assistance of her husband with dressing of lower extremities and with household chores.

Following her three week stay at the SNF Mrs. J. progressed from NWB to PWB 50% on LLE with a splint and was ambulating with a rolling walker 60’ x 2 with minimal assistance, transferred with minimal assistance and was partial weight bearing on the left. During this time an increase in function, strength and safety awareness was noted.

With a strong desire to return home with her husband discharge was arranged with home health care to include continuation of physical and occupational therapy, instructions to follow up with her primary care and orthopedic physicians. The SNF updated Mrs. J’s personal health record (PHR) to reflect the care and treatment she had received over the past three weeks. At follow up appointments with her primary and ortho physicians she was able to provide a history of medications received while at the SNF as well as those ordered on discharged. Reports of various test results were available as well as a history of vital signs and weights. Finally, the therapists were able to document the beginning and ending functional status changes.