# Langcare Langcare MCP Fhir Discharge Planning Checklist > Discharge Planning Checklist - Skill: `tomevault-io/langcare-langcare-mcp-fhir-discharge-planning-checklist` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-discharge-planning-checklist` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-discharge-planning-checklist/raw - Safety review: pending (external: skill-scanner PASS, skillspector PASS) - Works with: Claude Code, Claude.ai, OpenAI Codex - Category: AI & ML - Author: tomevault-io (https://skillmd.com/u/tomevault-io) - Updated: 2026-09-17 - Page: https://skillmd.com/skills/tomevault-io/langcare-langcare-mcp-fhir-discharge-planning-checklist --- # Discharge Planning Checklist ## Overview Assess discharge readiness by querying FHIR resources for pending orders, incomplete care plan tasks, unscheduled follow-ups, and unreconciled medications. Generate a structured checklist with pass/fail status for each CMS Condition of Participation discharge requirement. Calculate LACE readmission risk index. Create or update a discharge CarePlan resource with outstanding tasks. ## FHIR Resources Used | Resource | Purpose | Key Fields | |----------|---------|------------| | ServiceRequest | Pending labs, imaging, consults | status, intent, code, authoredOn | | CarePlan | Discharge plan with tasks | status, intent, activity, category | | Appointment | Scheduled follow-ups | status, serviceType, start, participant | | MedicationRequest | Active prescriptions for reconciliation | status, medicationCodeableConcept, dosageInstruction | | MedicationStatement | Patient-reported medications | status, medicationCodeableConcept | | Encounter | Current admission details | status, class, period, reasonCode | | Condition | Active problems for discharge summary | clinicalStatus, code, onsetDateTime | | Procedure | Completed procedures during stay | status, code, performedDateTime | | Observation | Pending lab results | status, code, valueQuantity | | DocumentReference | Patient education materials | type, status, content | | DeviceRequest | DME orders | status, codeCodeableConcept, intent | ## Instructions ### Step 1: Retrieve Current Encounter ``` Tool: fhir_search resourceType: "Encounter" queryParams: "patient=[patient-id]&status=in-progress&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|IMP" ``` Extract: admission date from `period.start`, reason for admission from `reasonCode`, attending provider from `participant`. If no in-progress inpatient encounter found, search for `status=finished` with most recent date. ### Step 2: Check Pending ServiceRequests ``` Tool: fhir_search resourceType: "ServiceRequest" queryParams: "patient=[patient-id]&status=active,draft&encounter=[encounter-id]" ``` Categorize pending requests: - **Lab orders**: `category.coding.code` = "108252007" (SNOMED: Laboratory procedure) - **Imaging orders**: `category.coding.code` = "363679005" (SNOMED: Imaging) - **Consult requests**: `category.coding.code` = "11429006" (SNOMED: Consultation) - **Referrals**: `category.coding.code` = "3457005" (SNOMED: Patient referral) Flag any active or draft ServiceRequest as a discharge blocker. ### Step 3: Check Pending Lab Results ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&status=preliminary,registered&category=laboratory" ``` Any Observation with status `preliminary` or `registered` indicates pending results. Flag as discharge blocker if ordered during current encounter. ### Step 4: Verify Medication Reconciliation ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active&encounter=[encounter-id]" ``` Also retrieve: ``` Tool: fhir_search resourceType: "MedicationStatement" queryParams: "patient=[patient-id]&status=active" ``` Compare MedicationRequest (inpatient orders) against MedicationStatement (home medications): - Identify new medications added during admission - Identify home medications held or discontinued - Flag unreconciled discrepancies (medication in one list but not addressed in the other) - Check that discharge prescriptions exist for all intended outpatient medications ### Step 5: Check Follow-up Appointments ``` Tool: fhir_search resourceType: "Appointment" queryParams: "patient=[patient-id]&status=booked,proposed&date=ge[today]" ``` Verify at minimum: - PCP follow-up within 7 days (14 days acceptable for low-risk) - Specialist follow-up if condition warrants (e.g., cardiology after MI, surgery after procedure) - Lab recheck appointment if indicated Flag as incomplete if no future appointments found. ### Step 6: Review CarePlan for Discharge Tasks ``` Tool: fhir_search resourceType: "CarePlan" queryParams: "patient=[patient-id]&status=active&category=http://snomed.info/sct|58000006" ``` SNOMED 58000006 = Discharge planning. Check `activity` array for incomplete tasks. If no discharge CarePlan exists, create one in Step 9. ### Step 7: Check Patient Education Documentation ``` Tool: fhir_search resourceType: "DocumentReference" queryParams: "patient=[patient-id]&type=http://loinc.org|69981-9&date=ge=[admission-date]" ``` LOINC 69981-9 = Patient education note. Verify education documented for: - Primary diagnosis - New medications (purpose, dosing, side effects) - Activity restrictions - Warning signs requiring return to ED - Follow-up instructions ### Step 8: Check DME and Home Health Orders ``` Tool: fhir_search resourceType: "DeviceRequest" queryParams: "patient=[patient-id]&status=active,draft&encounter=[encounter-id]" ``` Also check for home health referrals: ``` Tool: fhir_search resourceType: "ServiceRequest" queryParams: "patient=[patient-id]&category=http://snomed.info/sct|385763009&status=active,draft" ``` SNOMED 385763009 = Home health care. Verify all DME and home health orders have been placed, not just drafted. ### Step 9: Calculate LACE Readmission Risk Index Gather data for LACE score calculation: - **L** (Length of stay): Calculate from `Encounter.period.start` to today - **A** (Acuity of admission): Check if admission was via ED (`Encounter.hospitalization.admitSource`) - **C** (Comorbidities): Count via Charlson comorbidity conditions from active Conditions - **E** (ED visits): Count Encounter resources with `class` = "EMER" in prior 6 months ``` Tool: fhir_search resourceType: "Encounter" queryParams: "patient=[patient-id]&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|EMER&date=ge[6-months-ago]" ``` Score interpretation: 0-4 Low risk, 5-9 Moderate risk, 10+ High risk. See `references/lace-index.md` for detailed scoring. ### Step 10: Generate or Update Discharge CarePlan If CarePlan exists from Step 6: ``` Tool: fhir_update resourceType: "CarePlan" id: "[careplan-id]" resource: { "status": "active", "intent": "plan", "subject": { "reference": "Patient/[patient-id]" }, "encounter": { "reference": "Encounter/[encounter-id]" }, "category": [{ "coding": [{ "system": "http://snomed.info/sct", "code": "58000006", "display": "Discharge planning" }] }], "activity": [ { "detail": { "status": "[completed|in-progress|not-started]", "description": "Pending lab results reviewed" } }, { "detail": { "status": "[completed|in-progress|not-started]", "description": "Medication reconciliation completed" } }, { "detail": { "status": "[completed|in-progress|not-started]", "description": "Follow-up appointments scheduled" } }, { "detail": { "status": "[completed|in-progress|not-started]", "description": "Patient education completed" } }, { "detail": { "status": "[completed|in-progress|not-started]", "description": "DME ordered" } }, { "detail": { "status": "[completed|in-progress|not-started]", "description": "Home health referral placed" } } ] } ``` If no CarePlan exists, use `fhir_create` with the same payload (omit `id`). ### Step 11: Format Output ``` DISCHARGE READINESS CHECKLIST ============================== Patient: [name] | MRN: [mrn] | Admission: [date] | LOS: [days] days LACE Score: [score] ([Low/Moderate/High] readmission risk) [PASS] / [FAIL] Pending Labs/Imaging - [list pending items or "All results finalized"] [PASS] / [FAIL] Medication Reconciliation - New: [count] medications added - Discontinued: [count] medications stopped - Unreconciled: [count] discrepancies [PASS] / [FAIL] Follow-up Appointments - PCP: [date] with [provider] or "NOT SCHEDULED" - Specialist: [date] with [provider] or "NOT SCHEDULED" [PASS] / [FAIL] Patient Education - [list topics documented or "NOT DOCUMENTED"] [PASS] / [FAIL] DME Orders - [list items or "No DME required" or "PENDING"] [PASS] / [FAIL] Home Health Referral - [status or "Not indicated" or "PENDING"] OVERALL: [READY / NOT READY - X items require attention] ``` ## Examples ### Example 1: Patient Ready for Discharge **User says:** "Is patient 67890 ready for discharge?" **Actions:** 1. `fhir_search` Encounter?patient=67890&status=in-progress&class=IMP -- returns encounter E-100, admitted 3 days ago for pneumonia 2. `fhir_search` ServiceRequest?patient=67890&status=active,draft&encounter=E-100 -- returns 0 (all orders completed) 3. `fhir_search` Observation?patient=67890&status=preliminary,registered&category=laboratory -- returns 0 (all results final) 4. `fhir_search` MedicationRequest?patient=67890&status=active&encounter=E-100 -- returns 3 inpatient meds 5. `fhir_search` MedicationStatement?patient=67890&status=active -- returns 5 home meds, all reconciled 6. `fhir_search` Appointment?patient=67890&status=booked&date=ge2024-01-15 -- returns PCP in 5 days, pulmonology in 14 days 7. `fhir_search` CarePlan?patient=67890&status=active&category=58000006 -- returns active discharge plan, all activities completed 8. `fhir_search` DocumentReference?patient=67890&type=69981-9 -- returns education note for pneumonia, antibiotics 9. Calculate LACE: L=3, A=1 (ED admit), C=2, E=0 -- Score: 6 (Moderate) **Result:** ``` DISCHARGE READINESS CHECKLIST ============================== Patient: Robert Chen | MRN: 67890 | Admission: 2024-01-12 | LOS: 3 days LACE Score: 6 (Moderate readmission risk) [PASS] Pending Labs/Imaging - All results finalized [PASS] Medication Reconciliation - 3 new (levofloxacin, guaifenesin, albuterol), 0 discontinued, 0 unreconciled [PASS] Follow-up Appointments - PCP: 2024-01-20, Pulmonology: 2024-01-29 [PASS] Patient Education - Pneumonia care, antibiotics, return precautions documented [PASS] DME Orders - No DME required [PASS] Home Health Referral - Not indicated OVERALL: READY - All discharge criteria met ``` ### Example 2: Patient Not Ready -- Multiple Blockers **User says:** "Run discharge checklist for patient abc-222" **Actions:** 1. `fhir_search` Encounter -- returns E-500, admitted 7 days ago for CHF exacerbation 2. `fhir_search` ServiceRequest?status=active,draft -- returns 2: pending echocardiogram, pending cardiology consult 3. `fhir_search` Observation?status=preliminary -- returns 1: BNP result pending 4. `fhir_search` MedicationRequest -- returns 6 inpatient meds 5. `fhir_search` MedicationStatement -- returns 4 home meds, 2 unreconciled (new carvedilol, dose change on furosemide) 6. `fhir_search` Appointment?status=booked -- returns 0 future appointments 7. `fhir_search` CarePlan -- returns plan with 2/6 activities completed 8. `fhir_search` DocumentReference -- returns 0 education documents 9. LACE: L=7, A=1, C=4 (CHF, DM, CKD, HTN), E=2 -- Score: 14 (High) **Result:** ``` DISCHARGE READINESS CHECKLIST ============================== Patient: Dorothy Williams | MRN: abc-222 | Admission: 2024-01-08 | LOS: 7 days LACE Score: 14 (High readmission risk) [FAIL] Pending Labs/Imaging - Echocardiogram: ordered, not completed - BNP (LOINC 42637-9): result pending - Cardiology consult: requested, not completed [FAIL] Medication Reconciliation - New: carvedilol 12.5mg BID (not yet reconciled with home list) - Changed: furosemide 20mg -> 40mg BID (dose change not documented) - 2 unreconciled discrepancies [FAIL] Follow-up Appointments - PCP: NOT SCHEDULED - Cardiology: NOT SCHEDULED - Lab recheck (BMP for electrolytes): NOT SCHEDULED [FAIL] Patient Education - NOT DOCUMENTED (CHF self-management, daily weights, sodium restriction, medication changes) [PASS] DME Orders - Home scale for daily weights ordered [FAIL] Home Health Referral - PENDING (draft order exists, not finalized) OVERALL: NOT READY - 5 items require attention ``` ## Troubleshooting ### No Inpatient Encounter Found - Patient may be in observation status. Search with `class=http://terminology.hl7.org/CodeSystem/v3-ActCode|OBSENC` for observation encounters. - Some systems use `status=planned` for encounters not yet started. Broaden search: `status=in-progress,planned,arrived`. ### ServiceRequest Search Returns Orders From Prior Encounters - Always filter by `encounter=[encounter-id]` to scope to current admission. - If encounter ID is unavailable, filter by `authored=ge[admission-date]` to approximate. ### Medication Reconciliation Shows False Discrepancies - Some systems use MedicationRequest for both inpatient and outpatient orders. Check `intent` field: `order` = active prescription, `plan` = intended but not yet ordered. - Brand vs generic name mismatches are common. Compare by RxNorm code (`medicationCodeableConcept.coding` where `system` = "http://www.nlm.nih.gov/research/umls/rxnorm") rather than display text. ## Related Skills - `transition-of-care-summary` -- generate the actual discharge/transfer document after checklist passes - `medication-reconciliation` -- detailed medication reconciliation workflow - `follow-up-task-generator` -- create Task resources for post-discharge follow-up items --- > Converted and distributed by [TomeVault](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.