langcare-transitions-of-care

name	langcare-transitions-of-care
description	Generates a structured transition-of-care summary using the I-PASS framework for safe patient handoffs between care settings. Compiles illness severity, patient summary, action list, situation awareness, and synthesis from FHIR data. Use when asked for transition of care summary, handoff, transfer summary, or I-PASS handoff.

Transitions of Care Summary

When to Use This Skill

Use when a clinician needs a structured care transition document for transfers between inpatient units, facilities, or inpatient-to-outpatient handoffs.

Clinical Workflow

1. Use fhir_search to retrieve the current Encounter with admission details
2. Use fhir_read to retrieve Patient demographics
3. Use fhir_search to pull active Conditions for illness severity and problem list
4. Use fhir_search to pull active MedicationRequest for current medication list
5. Use fhir_search to pull recent Observation resources (vitals, labs) for clinical status
6. Use fhir_search to pull pending ServiceRequest resources for action items
7. Use fhir_search to pull active CarePlan for ongoing care goals
8. Structure output using I-PASS framework (see references/ipass-framework.md): Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver
9. Use fhir_create to create DocumentReference with the transition summary

FHIR Resources

• Encounter -- Current admission context, reason, period
• Patient -- Demographics
• Condition -- Active problems, admission diagnosis
• MedicationRequest -- Current medications
• Observation -- Recent vitals and labs
• ServiceRequest -- Pending orders and action items
• CarePlan -- Active care plans and goals
• DocumentReference -- Output: transition summary document

FHIR Query Examples

Pull Current Encounter

fhir_search(resourceType="Encounter", queryParams="patient=[patient-id]&status=in-progress&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|IMP")

Pull Pending Actions

fhir_search(resourceType="ServiceRequest", queryParams="patient=[patient-id]&status=active,draft&encounter=[encounter-id]")

Clinical Guidelines

• I-PASS Study Group (Starmer et al., NEJM 2014): Standardized handoff reduces medical errors
• Joint Commission NPSG.02.05.01: Standardize approach to hand-off communications
• CMS Conditions of Participation for discharge/transfer documentation

Interpretation Guide

• I-PASS structure: I = Illness severity (stable/watcher/unstable); P = Patient summary (one-liner, key events, ongoing issues); A = Action list (to-do items with responsible party and timeline); S = Situation awareness (what to watch for, contingency plans); S = Synthesis (receiver read-back confirmation)
• Include code status, allergies, isolation precautions, and fall risk in every handoff
• Flag anticipatory guidance: potential complications, if-then plans, escalation criteria

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges