# Langcare Langcare MCP Fhir Transition Of Care Summary > Transition of Care Summary - Skill: `tomevault-io/langcare-langcare-mcp-fhir-transition-of-care-summary` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-transition-of-care-summary` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-transition-of-care-summary/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-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 | Resource | Purpose | Key Fields | |----------|---------|------------| | Patient | Demographics and identifiers | name, birthDate, gender, identifier, address, telecom | | Encounter | Current/recent encounter details | status, class, period, reasonCode, participant, hospitalization | | Condition | Active problems and hospital diagnoses | code, clinicalStatus, verificationStatus, onsetDateTime, category | | MedicationRequest | Discharge/current prescriptions | medicationCodeableConcept, dosageInstruction, status, intent | | MedicationStatement | Home medication list | medicationCodeableConcept, status, dosage | | AllergyIntolerance | Allergies and adverse reactions | code, reaction, clinicalStatus, criticality | | Procedure | Procedures performed during stay | code, performedDateTime, status, outcome | | Observation | Labs, vitals, functional status | code, valueQuantity, effectiveDateTime, interpretation | | DiagnosticReport | Imaging and pathology results | code, conclusion, effectiveDateTime, status | | Immunization | Immunization history | vaccineCode, occurrenceDateTime, status | | CarePlan | Active care plans | status, category, activity, goal | | Consent | Advance directives, code status | category, status, provision | | DocumentReference | Store the generated TOC | type, content, context | | ServiceRequest | Pending orders and referrals | status, code, intent | | Goal | Treatment goals | lifecycleStatus, description, target | ## 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 --- > Converted and distributed by [TomeVault](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.