| name | langcare-discharge-summaries |
| description | Generates comprehensive discharge summary documents from FHIR data including admission diagnosis, hospital course, procedures, discharge medications, follow-up instructions, and pending results. Use when asked to write a discharge summary, generate discharge documentation, or create a hospital discharge note.
|
Discharge Summary Writer
When to Use This Skill
Use when a clinician needs a comprehensive discharge summary document compiled from the patient's hospital course in FHIR.
Clinical Workflow
- Use
fhir_search to retrieve the Encounter (admission date, discharge date, reason, attending)
- Use
fhir_read to retrieve Patient demographics
- Use
fhir_search to pull Condition resources: admitting diagnosis, discharge diagnoses, complications
- Use
fhir_search to pull Procedure resources performed during the hospitalization
- Use
fhir_search to pull active MedicationRequest for discharge medications; compare against admission medications for reconciliation summary
- Use
fhir_search to pull key Observation results (admission labs, discharge labs, significant findings)
- Use
fhir_search to pull ServiceRequest resources for pending results and referrals
- Use
fhir_search to pull scheduled Appointments for follow-up
- Assemble discharge summary: demographics, admission/discharge dates, admitting diagnosis, hospital course, procedures, discharge diagnoses, discharge medications, follow-up, pending results, patient instructions
- Use
fhir_create to persist as DocumentReference (LOINC 18842-5)
FHIR Resources
- Encounter -- Admission/discharge dates, reason, attending
- Patient -- Demographics
- Condition -- Admitting and discharge diagnoses
- Procedure -- Inpatient procedures
- MedicationRequest -- Discharge medications
- Observation -- Key lab results
- Appointment -- Follow-up appointments
- ServiceRequest -- Pending results, referrals
- DocumentReference -- Output: discharge summary
FHIR Query Examples
Pull Encounter
fhir_read(resourceType="Encounter", id="[encounter-id]")
Pull Procedures During Admission
fhir_search(resourceType="Procedure", queryParams="patient=[patient-id]&encounter=[encounter-id]")
Clinical Guidelines
- CMS Conditions of Participation require discharge summary within 30 days
- Joint Commission: discharge summary must include reason for admission, significant findings, procedures, discharge condition, discharge medications, follow-up instructions, pending results
- TJC NPSG.02.03.01: communicate pending test results to outpatient provider
Interpretation Guide
- Hospital course: narrative summary of key events, procedures, complications, and clinical response to treatment
- Discharge medications: full list with dose, frequency, route; highlight NEW medications and CHANGED medications vs pre-admission
- Pending results: list any results not yet available at discharge with responsible provider for follow-up
- Follow-up: specific provider names, dates, and purpose
- Patient instructions: diagnosis-specific education, activity restrictions, warning signs for ED return, diet modifications
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
