Langcare Langcare MCP Fhir Transition Of Care Summary

Transition of Care Summary

Overview

Generate a comprehensive transition of care document containing all required C-CDA sections for patient handoff. Pull all relevant FHIR resources to create a complete clinical picture. Output a structured summary organized by Joint Commission TOC requirements. Create a DocumentReference FHIR resource linking to the generated summary.

FHIR Resources Used

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract: full legal name, DOB, age, gender, MRN, address, phone, preferred language, emergency contacts (from contact array or RelatedPerson search).

Step 2: Retrieve Encounter Information

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&_sort=-date&_count=1"

Extract: encounter type (inpatient, observation, ED), admission date, discharge date (if available), reason for admission from reasonCode, attending provider from participant, discharge disposition from hospitalization.dischargeDisposition.

Step 3: Retrieve Active Problem List

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Organize by:

• Principal diagnosis: The primary reason for the encounter
• Active problems: All other active conditions
• Hospital-acquired conditions: Conditions with onset during the encounter period
• Include SNOMED or ICD-10 codes, onset dates, and verification status

Step 4: Retrieve Medication Lists

Discharge medications:

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&intent=order"

Home medication list for comparison:

Tool: fhir_search
resourceType: "MedicationStatement"
queryParams: "patient=[patient-id]&status=active"

For each medication, extract: name, dose, route, frequency, prescriber, start date. Flag:

• NEW: Medications started during encounter
• CHANGED: Medications with dose or frequency modifications
• DISCONTINUED: Medications intentionally stopped (search MedicationRequest with status=stopped or status=cancelled)
• CONTINUED: Medications unchanged from pre-admission

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=stopped,cancelled&encounter=[encounter-id]"

Step 5: Retrieve Allergies

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]"

Include: allergen, reaction type, severity, criticality. If zero results, document as "No Known Allergies (NKA)" or "Allergy status not reviewed" (these are clinically different).

Step 6: Retrieve Procedures Performed

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&date=ge=[encounter-start-date]&status=completed"

Include: procedure name with code, date performed, performer, outcome/findings. For surgical procedures, include anesthesia type and complications if documented.

Step 7: Retrieve Recent Results

Lab results:

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge=[encounter-start-date]&_sort=-date"

Imaging results:

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&date=ge=[encounter-start-date]&_sort=-date"

Flag any results with status preliminary or registered as PENDING. Include interpretation flags for abnormal values.

Step 8: Retrieve Most Recent Vitals

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=vital-signs&_sort=-date&_count=10"

Extract the most recent value for: BP (85354-9), HR (8867-4), RR (9279-1), Temp (8310-5), SpO2 (2708-6), Weight (29463-7).

Step 9: Check Advance Directives and Code Status

Tool: fhir_search
resourceType: "Consent"
queryParams: "patient=[patient-id]&category=http://terminology.hl7.org/CodeSystem/consentcategorycodes|acd"

Also check for resuscitation status:

Tool: fhir_search
resourceType: "Consent"
queryParams: "patient=[patient-id]&category=http://terminology.hl7.org/CodeSystem/consentcategorycodes|dnr"

If no Consent resources found, check Condition for code status documentation (some systems store as Observation or flag).

Step 10: Retrieve Pending Orders and Follow-up Needs

Tool: fhir_search
resourceType: "ServiceRequest"
queryParams: "patient=[patient-id]&status=active,draft"

Tool: fhir_search
resourceType: "CarePlan"
queryParams: "patient=[patient-id]&status=active"

Identify: pending labs awaiting results, scheduled follow-up appointments, home health orders, DME orders, referrals in progress.

Step 11: Retrieve Immunization History

Tool: fhir_search
resourceType: "Immunization"
queryParams: "patient=[patient-id]&status=completed&_sort=-date"

Include recent immunizations (administered during encounter) and relevant historical immunizations (pneumococcal, influenza, COVID-19, tetanus).

Step 12: Retrieve Functional Status

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=survey&_sort=-date&_count=5"

Look for: ADL assessments, mobility status, cognitive assessments (MMSE, MoCA), fall risk, Braden scale.

Step 13: Create DocumentReference

Tool: fhir_create
resourceType: "DocumentReference"
resource: {
  "resourceType": "DocumentReference",
  "status": "current",
  "type": { "coding": [{ "system": "http://loinc.org", "code": "18761-7", "display": "Transfer summary note" }] },
  "category": [{ "coding": [{ "system": "http://loinc.org", "code": "18842-5", "display": "Discharge summary" }] }],
  "subject": { "reference": "Patient/[patient-id]" },
  "date": "[current-timestamp]",
  "author": [{ "reference": "Practitioner/[author-id]" }],
  "description": "Transition of Care Summary",
  "content": [{ "attachment": { "contentType": "text/plain", "data": "[base64-encoded-summary]" } }],
  "context": { "encounter": [{ "reference": "Encounter/[encounter-id]" }] }
}

Step 14: Format Output

Use the I-PASS structure for the summary (see references/handoff-frameworks.md):

TRANSITION OF CARE SUMMARY
============================
Generated: [timestamp]
DocumentReference: DocumentReference/[id]

PATIENT INFORMATION
-------------------
Name: [full name] | DOB: [date] (Age: [age]) | Sex: [gender]
MRN: [mrn] | Language: [preferred language]
Emergency Contact: [name] - [relationship] - [phone]

ENCOUNTER DETAILS
-----------------
Type: [Inpatient/Observation/ED]
Admitted: [date] | Discharged: [date]
Attending: [provider name]
Admit Reason: [reason]
Discharge Disposition: [home/SNF/rehab/etc.]

I - ILLNESS SEVERITY
---------------------
Principal Diagnosis: [diagnosis] ([code])
Active Problems:
  1. [condition] - onset [date] ([code])
  2. [condition] - onset [date] ([code])

P - PATIENT SUMMARY
--------------------
Hospital Course:
[Brief narrative of what happened during the stay]

Procedures Performed:
  1. [procedure] - [date] - [outcome]
  2. [procedure] - [date] - [outcome]

Key Results:
  Labs:
    - [lab]: [value] [units] ([date]) [flag]
    - [lab]: [value] [units] ([date]) [flag]
  Imaging:
    - [study]: [key finding] ([date])

Most Recent Vitals:
  BP: [value] | HR: [value] | RR: [value] | Temp: [value] | SpO2: [value]

A - ACTION LIST
---------------
Pending Results:
  - [test]: ordered [date], result pending

Follow-up Appointments:
  - [specialty]: [date] with [provider]
  - [specialty]: [date] with [provider]

Pending Referrals:
  - [referral type]: [status]

S - SITUATION AWARENESS
-----------------------
Code Status: [Full code / DNR / DNR-DNI / POLST on file]
Advance Directive: [On file / Not on file]

Medications (Discharge):
  NEW:
    - [medication] [dose] [route] [frequency] - Reason: [indication]
  CHANGED:
    - [medication] [old dose] -> [new dose] - Reason: [why changed]
  DISCONTINUED:
    - [medication] - Reason: [why stopped]
  CONTINUED:
    - [medication] [dose] [route] [frequency]

Allergies:
  - [allergen]: [reaction] (Severity: [severity])

S - SYNTHESIS BY RECEIVER
--------------------------
Contingency Plans:
  - If [scenario], then [action]
  - If [scenario], then [action]

Diet: [restrictions]
Activity: [restrictions]
Weight: [daily weights? fluid restriction?]
Warning Signs: [symptoms requiring medical attention]

IMMUNIZATION STATUS
-------------------
  - [vaccine]: [date] [status]

FUNCTIONAL STATUS
-----------------
  Mobility: [status]
  ADLs: [status]
  Cognition: [status]

Examples

Example 1: Post-MI Transfer to Cardiac Rehab

User says: "Generate a transition of care summary for patient 77777 being transferred to cardiac rehab"

Actions:

1. fhir_read Patient/77777 -- returns William Thompson, 71yo Male
2. fhir_search Encounter (most recent) -- inpatient E-300, admitted 5 days ago for STEMI
3. fhir_search Condition?clinical-status=active -- STEMI, HTN, HLD, T2DM
4. fhir_search MedicationRequest?status=active -- aspirin, clopidogrel, atorvastatin 80mg (NEW), metoprolol 25mg (NEW), lisinopril (CONTINUED), metformin (CONTINUED)
5. fhir_search MedicationRequest?status=stopped -- amlodipine (DISCONTINUED, BP well controlled on new regimen)
6. fhir_search AllergyIntolerance -- PCN (hives), sulfa (rash)
7. fhir_search Procedure -- PCI with DES to LAD (day 1), echocardiogram (day 2)
8. fhir_search Observation?category=laboratory -- troponin peaked at 12.4 (now trending down), Cr 1.1, HbA1c 7.2%
9. fhir_search Observation?category=vital-signs -- BP 128/78, HR 68, SpO2 97%
10. fhir_search Consent -- Full code
11. fhir_search ServiceRequest?status=active -- cardiac rehab referral active
12. fhir_create DocumentReference -- TOC document created

Result: Summary includes principal diagnosis (STEMI), procedure (PCI with DES to LAD), medication changes (new DAPT, statin, beta-blocker), discharge to cardiac rehab, follow-up with cardiology in 2 weeks, contingency plans for chest pain recurrence.

Example 2: SNF Transfer for Elderly Patient Post Hip Fracture

User says: "Create transfer summary for patient abc-888 going to skilled nursing"

Actions:

1. fhir_read Patient/abc-888 -- returns Margaret O'Brien, 84yo Female
2. fhir_search Encounter -- inpatient E-450, admitted 8 days ago for hip fracture
3. fhir_search Condition -- right hip fracture, osteoporosis, dementia (mild), CHF, hypothyroidism
4. fhir_search MedicationRequest?status=active -- 12 active medications including enoxaparin (NEW), calcium/vitamin D (NEW), acetaminophen PRN (NEW)
5. fhir_search MedicationRequest?status=stopped -- ibuprofen (DISCONTINUED due to surgical risk + CKD)
6. fhir_search AllergyIntolerance -- codeine (nausea), latex
7. fhir_search Procedure -- right hip ORIF (day 1)
8. fhir_search Observation?category=laboratory -- Hgb 9.8, Cr 1.4, INR 1.0
9. fhir_search Observation?category=vital-signs -- stable vitals
10. fhir_search Consent -- DNR, advance directive on file with daughter as HCP
11. fhir_search Observation?category=survey -- Braden 16 (mild risk), AMT 7/10, requires 2-person assist for transfers
12. fhir_create DocumentReference

Result: Summary includes surgical details (ORIF), VTE prophylaxis plan (enoxaparin x28 days), weight-bearing restrictions (TDWB right lower extremity), fall prevention with dementia precautions, PT/OT goals, code status (DNR), HCP contact information, wound care instructions, and SNF-specific contingency plans.

Troubleshooting

Encounter Resource Missing Key Fields

• Not all FHIR servers populate hospitalization.dischargeDisposition or reasonCode. Check the Condition list for the principal diagnosis and ask the user for discharge disposition if not in the Encounter resource.
• If participant (attending provider) is empty, check ServiceRequest or Procedure resources for a performer reference.

Medication Reconciliation Discrepancies Between MedicationRequest and MedicationStatement

• MedicationStatement represents what the patient reports taking. MedicationRequest represents what was prescribed. Discrepancies are expected and clinically significant.
• Present both lists and flag discrepancies. The TOC should clearly indicate which list is "discharge medications" (MedicationRequest with intent=order, status=active) vs "home medications prior to admission" (MedicationStatement).

No Advance Directive or Code Status Found

• Code status may be stored differently across systems: as Consent, as a flag on the Patient resource, as an Observation, or only in clinical notes.
• If not found in structured data, note "Code status not documented in structured data -- verify with clinical team before transfer."
• This is a Joint Commission requirement for TOC. Flag it prominently if missing.

Related Skills

• discharge-planning-checklist -- run before generating TOC to ensure readiness
• medication-reconciliation -- detailed medication comparison and reconciliation
• follow-up-task-generator -- create structured follow-up tasks from the TOC action items

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