Messages & records
Everything anyone said, in one place
Engage is the messaging rail — but for a household two weeks out of hospital, the record is the product. The discharge summary the family lost, the surgeon's weight-bearing instructions, what the physio actually measured. All of it here, and a way to feed in documents from hospitals that aren't on MatrixCare.
Care circle
5people
Each with their own permissions
Documents on file
5
3 turned into plan items
Upcoming
4
Two booked by family directly
Loneliness screening
6/ 9
moderate · moved from low on Aug 7, 2026
Bring in a discharge summary
PDF, photo of a printout, or a direct pull from Epic, Cerner, MEDITECH, or Athena
- ✓Step 1
Read
Text and tables lifted from the PDF, including scanned pages
- ✓Step 2
Understand
Medications, activity limits, follow-ups and wound care identified
- ✓Step 3
Reconcile
Checked against her existing medication list — three changes found
- ✓Step 4
Turn into a plan
Daily tasks, calendar entries and family instructions created
- ✓Step 5
Confirm with the nurse
Tomás reviewed and approved before anything went live
Safety gate. Nothing extracted from a document reaches the resident's plan until a clinician approves it. Parsing a discharge summary wrong is a patient-safety event, not a bug.
Clinical documents
What each document produced, and who in the circle can open it.
Discharge summary — left TKA
Discharge summaryTurned into plan itemsJul 29, 2026 · Mission Hospital · Dr. P. Shah · 6 pages
Shared with Sarah, Marguerite (POA), Tomás Reyes, RN
- 5 recovery tasks added to her daily plan
- 3 medication changes reconciled against the pillbox
- Day-14 physio review placed on the calendar
- Weight-bearing and walker instructions surfaced to the family
- Wound-care instructions matched to a ViewMedica animation
Operative note
Operative noteJul 26, 2026 · Dr. P. Shah · 3 pages
Shared with Marguerite (POA), Tomás Reyes, RN
Home health PT — initial evaluation
TherapyTurned into plan itemsJul 31, 2026 · Mountain Physical Therapy · 2 pages
Shared with Sarah, Tomás Reyes, RN
- Baseline knee flexion 68° recorded
- Exercise programme added to the daily plan
Post-op radiograph — left knee
ImagingJul 27, 2026 · Mission Radiology · 1 pages
Shared with Tomás Reyes, RN
Basic metabolic panel + CBC
LabsTurned into plan itemsJul 28, 2026 · Mission Laboratory · 2 pages
Shared with Tomás Reyes, RN, Dr. Whitmore
- Baseline glucose and creatinine stored for comparison
Health profile
Pulled from the record. Every line says where it came from.
This episode
- Procedure
- Left total knee arthroplasty
- Mission Hospital · operative note
- Surgery date
- July 26, 2026
- Mission Hospital
- Discharged
- July 29, 2026 — home with home health
- Discharge summary
- Weight-bearing
- Weight-bearing as tolerated, walker for 14 days
- Discharge summary
- Follow-up
- Day-14 physio review · Wed Aug 12
- Discharge summary
Conditions
- Type 2 diabetes
- Diagnosed 2011 · HbA1c 7.0% (Jun 2026)
- MatrixCare problem list
- Hypertension
- Diagnosed 2008 · controlled
- MatrixCare problem list
- Osteoarthritis
- Left knee — resolved by arthroplasty; right knee mild
- MatrixCare problem list
- Hearing
- Mild bilateral loss, no aids
- MatrixCare problem list
Allergies & precautions
- Allergies
- Sulfa drugs — rash
- MatrixCare
- Food
- No shellfish (preference, not allergy)
- Set by Eleanor
- Falls risk
- Elevated — post-op, walker, lives alone
- Discharge assessment
Care team
- Surgeon
- Dr. Priyanka Shah, MD — Mission Orthopaedics
- EHR
- Primary care
- Dr. Alan Whitmore, MD
- EHR
- Case manager
- Tomás Reyes, RN
- MatrixCare
- Dietitian
- Ana Petrova, RD CDCES
- MatrixCare
Messages
Care team and family in one thread, routed by role.
Tomás Reyes, RN · Today, 9:14 am · care team
Sarah — I saw the overnight pattern flagged this morning. Given the bathroom trips plus the appetite drop, I'd like to rule out a UTI before we assume it's the knee. Can we get a sample this week?Sarah Whitfield-Ruiz · Today, 9:31 am · care team
Yes — I can drive over Tuesday morning. Should I book the tele-visit too, or wait for results?Tomás Reyes, RN · Today, 9:36 am · care team
Book it for Wednesday afternoon — results should be back by then and we can decide in one conversation instead of three.Eleanor Whitfield · Today, 10:02 am
I'm fine, all of you. Just tired this week. But yes Sarah, come Tuesday — I'll make coffee.David Whitfield · Today, 11:47 am
Just landed. Reading back through this now — Sarah, tell me what you need me to cover.
Appointments
Booked by the family, not requested through a facility.
Grocery + meal delivery window
ConfirmedDelivery · Tomorrow, 11:00 am · MealTracker Fresh
Booked by Auto-scheduled
Sample collection + morning visit
ConfirmedIn person · Tue Aug 11, 9:00 am · Sarah Whitfield-Ruiz
Booked by Sarah Whitfield-Ruiz
Tele-visit — functional decline review
RequestedTele-visit · Wed Aug 12, 2:30 pm · Tomás Reyes, RN
Booked by Sarah Whitfield-Ruiz
Weekly wellness check-in call
ConfirmedCheck-in · Fri Aug 14, 10:00 am · Care team
Booked by Recurring
Loneliness screening
UCLA 3-item scale, run remotely through the Forms Center.
Loneliness is not a soft metric after surgery. Isolated patients move less, eat less, and are readmitted more — and it is the one signal a sensor cannot see alone. It needs the screening plus the door sensor plus the calendar.
Things she might actually go to
Hollis Lane neighborhood coffee hour
Saturdays, 10:00 am · 0.3 miles
Walking distance, and two of her existing contacts already attend
First Methodist choir — seated section
Thursdays, 6:30 pm · transport available
She attended for eleven years and declined only in the last two weeks
Library large-print book club
Every other Monday, 2:00 pm
Low mobility demand while the knee is flaring