transition-of-care-summary

name	transition-of-care-summary
description	Generates a C-CDA compliant transition of care document by pulling active problems, medications, allergies, recent procedures, pending results, code status, and follow-up needs from FHIR resources. Use when user asks to "generate TOC", "create transfer summary", "discharge summary", "handoff document", "transition of care", "care summary for transfer", or needs documentation for "sending patient to another facility". Do NOT use for discharge readiness checks, referral generation, or routine clinical summaries.
metadata	{"author":"LangCare","version":"1.0.0","mcp-server":"langcare-mcp-fhir","category":"care-coordination"}

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