Discharge Summary Writer

Overview

Generate comprehensive discharge summaries meeting CMS Conditions of Participation (CoP) and The Joint Commission (TJC) requirements. Pull admission and discharge diagnoses, hospital course data, procedures performed, discharge medication list with changes from admission highlighted, follow-up appointments, discharge condition, and generate patient-appropriate discharge instructions. Per CMS CoP 482.24(c)(2), discharge summaries must include: reason for hospitalization, significant findings, procedures performed, treatment rendered, patient condition at discharge, patient/family instructions, and attending signature.

FHIR Resources Used

Instructions

Step 1: Retrieve Encounter Details

Tool: fhir_read
resourceType: "Encounter"
id: "[encounter-id]"

Extract:

• Admission date: period.start
• Discharge date: period.end (or today if discharging now)
• Length of stay: Calculate from period
• Admission reason: reasonCode
• Discharge disposition: hospitalization.dischargeDisposition.coding[0].display
• Encounter diagnoses: diagnosis array with use.coding[0].code (AD = admission, DD = discharge)

Step 2: Retrieve Patient Demographics

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

Extract: name, DOB, age, gender, preferred language (for instruction readability), PCP from generalPractitioner.

Step 3: Pull Admission and Discharge Diagnoses

3a: Encounter-linked diagnoses

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&encounter=[encounter-id]"

3b: All active conditions at discharge

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

Separate into:

• Principal discharge diagnosis: Condition from encounter diagnosis list with rank=1 or use=DD
• Secondary diagnoses: Remaining encounter diagnoses
• Chronic conditions: Active conditions not linked to this encounter

Step 4: Pull Procedures Performed During Hospitalization

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

For each procedure:

• Name from code.coding[0].display
• Date from performedDateTime
• Outcome from outcome.coding[0].display if available
• Complications from complication if present

Step 5: Build Discharge Medication List with Changes

5a: Current discharge medications

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&intent=order&_count=100"

5b: Pre-admission home medications

Tool: fhir_search
resourceType: "MedicationStatement"
queryParams: "patient=[patient-id]&status=active,on-hold,completed&_count=100"

5c: Stopped medications

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=stopped,cancelled&authoredon=ge[admission-date]&_count=100"

Compare lists and categorize each medication:

• CONTINUE: Same medication, same dose as home
• NEW: Started during hospitalization (authoredOn >= admission date, no matching home med)
• CHANGED: Same medication, different dose/frequency/route
• DISCONTINUED: On home list but stopped during admission
• ON HOLD: Temporarily held (e.g., metformin held for contrast)

Step 6: Pull Significant Findings and Results

6a: Key diagnostic reports

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

6b: Discharge vitals

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

6c: Discharge labs (most recent)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&_sort=-date&_count=30"

Step 7: Pull Follow-Up Appointments

Tool: fhir_search
resourceType: "Appointment"
queryParams: "patient=[patient-id]&date=ge[discharge-date]&status=booked,proposed&_sort=date"

If no appointments found, flag as "No follow-up appointments scheduled -- ACTION REQUIRED."

Step 8: Pull Care Plan and Discharge Instructions

Tool: fhir_search
resourceType: "CarePlan"
queryParams: "patient=[patient-id]&status=active&_sort=-date&_count=5"

Step 9: Pull Allergies

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

Step 10: Assemble Discharge Summary

DISCHARGE SUMMARY
==================
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender]
Admission Date: [date] | Discharge Date: [date] | LOS: [n] days
Attending Physician: [name]
PCP: [name]

ADMISSION DIAGNOSIS
-------------------
[From encounter reasonCode or admission diagnosis]

DISCHARGE DIAGNOSES
-------------------
Principal: [diagnosis] - [ICD-10]
Secondary:
1. [diagnosis] - [ICD-10]
2. [diagnosis] - [ICD-10]

HOSPITAL COURSE
---------------
[Flag: "Hospital course narrative requires clinician input"]
[Pre-populate timeline from available data:]
- Day 1: Admitted for [reason]. Initial workup: [key labs, imaging].
- [Procedures performed with dates]
- [Significant medication changes with dates]
- [Key lab trends: admission -> discharge values]
- [Consults obtained]

PROCEDURES PERFORMED
--------------------
1. [Procedure name] - [date] - Outcome: [outcome]
2. [Procedure name] - [date] - Outcome: [outcome]

SIGNIFICANT FINDINGS
--------------------
[Key diagnostic report conclusions]
[Pathology results if applicable]

CONDITION AT DISCHARGE
----------------------
[Flag: "Clinician to specify: improved / stable / fair / guarded"]
Discharge Vitals: T [temp] | HR [hr] | BP [sys]/[dia] | RR [rr] | SpO2 [spo2]%

DISCHARGE MEDICATIONS
---------------------
[CONTINUE from home]
1. [Drug] [dose] [route] [frequency] - CONTINUE UNCHANGED

[NEW medications]
2. [Drug] [dose] [route] [frequency] - NEW: [indication]
3. [Drug] [dose] [route] [frequency] - NEW: [indication]

[CHANGED medications]
4. [Drug] [new dose] [route] [frequency] - CHANGED from [old dose]: [reason]

[DISCONTINUED medications]
5. [Drug] - DISCONTINUED: [reason]

ALLERGIES
---------
[allergy list]

FOLLOW-UP APPOINTMENTS
----------------------
1. [Provider/Specialty] - [date] [time] - [location]
2. [Provider/Specialty] - [date] [time] - [location]
[Or: "No follow-up scheduled -- SCHEDULE REQUIRED"]

PENDING RESULTS AT DISCHARGE
-----------------------------
[List any outstanding labs, pathology, cultures with expected completion]

PATIENT INSTRUCTIONS
--------------------
[Condition-specific discharge instructions]
[Activity restrictions]
[Diet instructions]
[Wound care if applicable]
[Return to ED if: warning signs]
[Flag: "Instructions should be at 5th-6th grade reading level per health literacy guidelines"]

CLINICIAN ATTESTATION
---------------------
[Flag: "Requires attending physician review and signature"]

Step 11: Persist as DocumentReference

Tool: fhir_create
resourceType: "DocumentReference"
resource: {
  "resourceType": "DocumentReference",
  "status": "current",
  "type": {
    "coding": [{
      "system": "http://loinc.org",
      "code": "18842-5",
      "display": "Discharge summary"
    }]
  },
  "subject": {"reference": "Patient/[patient-id]"},
  "date": "[current-datetime]",
  "author": [{"reference": "Practitioner/[practitioner-id]"}],
  "content": [{
    "attachment": {
      "contentType": "text/plain",
      "data": "[base64-encoded-summary]"
    }
  }],
  "context": {
    "encounter": [{"reference": "Encounter/[encounter-id]"}],
    "period": {
      "start": "[admission-date]",
      "end": "[discharge-date]"
    }
  }
}

Examples

Example 1: CHF Exacerbation Discharge

User says: "Write discharge summary for patient 54321, encounter ENC-ADM-200."

Actions:

1. fhir_read Encounter/ENC-ADM-200. Returns: admitted 2024-03-15, discharging 2024-03-19, LOS 4 days, reasonCode="Acute systolic heart failure exacerbation", discharge disposition="Home".
2. fhir_read Patient/54321. Returns: Robert Brown, DOB 1948-11-03, Male. PCP: Dr. Williams.
3. fhir_search Condition for encounter. Returns: Acute on chronic systolic HF (I50.22), hyponatremia (E87.1). Active: HTN, T2DM, CKD3, afib.
4. fhir_search Procedure for encounter. Returns: Echocardiogram (2024-03-16), right heart catheterization (2024-03-17).
5. fhir_search MedicationRequest active + MedicationStatement + stopped. Comparison yields:

• CONTINUE: apixaban 5mg BID, metoprolol 50mg BID, metformin 500mg BID
• NEW: spironolactone 25mg daily (indication: HFrEF), sacubitril/valsartan 24/26mg BID
• CHANGED: furosemide 40mg -> 80mg BID (from 40mg daily)
• DISCONTINUED: lisinopril 20mg daily (replaced by sacubitril/valsartan)

1. fhir_search DiagnosticReport. Returns: Echo EF 30%, moderate MR. RHC: elevated filling pressures.
2. fhir_search Observation labs. Returns: BNP 380 (down from 1250), Na 136 (up from 133), Cr 1.5 (down from 1.8), K 4.2.
3. fhir_search Appointment. Returns: Cardiology follow-up 2024-03-26, PCP 2024-04-02.

Result:

DISCHARGE SUMMARY
==================
Patient: Robert Brown | MRN: MRN-54321 | DOB: 1948-11-03 (Age: 75) | Sex: Male
Admission: 2024-03-15 | Discharge: 2024-03-19 | LOS: 4 days
Attending: Dr. Carter | PCP: Dr. Williams

DISCHARGE DIAGNOSES
Principal: Acute on chronic systolic heart failure exacerbation - I50.22
Secondary:
1. Hyponatremia, resolved - E87.1
2. Hypertension - I10
3. Atrial fibrillation - I48.91
4. CKD stage 3 - N18.3
5. Type 2 diabetes - E11.9

PROCEDURES
1. Transthoracic echocardiogram - 2024-03-16
2. Right heart catheterization - 2024-03-17

SIGNIFICANT FINDINGS
- Echo: EF 30% (down from 40% in 2023), moderate mitral regurgitation
- RHC: Elevated filling pressures consistent with decompensated HF

DISCHARGE MEDICATIONS
CONTINUE: Apixaban 5mg BID, Metoprolol 50mg BID, Metformin 500mg BID
NEW: Spironolactone 25mg daily (for HFrEF), Sacubitril/valsartan 24/26mg BID (for HFrEF)
CHANGED: Furosemide 80mg PO BID (was 40mg daily - increased for volume management)
DISCONTINUED: Lisinopril 20mg daily (replaced by sacubitril/valsartan - do NOT take together)

FOLLOW-UP
1. Cardiology (Dr. Patel) - 2024-03-26 - Heart failure clinic
2. PCP (Dr. Williams) - 2024-04-02
Lab check: BMP in 1 week (monitor K and Cr on new spironolactone)

Example 2: Pneumonia Discharge

User says: "DC summary for patient 67890, encounter ENC-MED-300."

Actions:

1. fhir_read Encounter/ENC-MED-300. Returns: admitted 2024-03-13, discharging 2024-03-17, LOS 4 days, CAP.
2. fhir_read Patient/67890. Returns: Alice Chen, DOB 1965-07-22, Female.
3. fhir_search Condition. Returns: CAP resolved, HTN, T2DM.
4. fhir_search MedicationRequest comparison: NEW: amoxicillin/clavulanate 875mg BID x 3 days (complete antibiotic course), azithromycin PO (transitioned from IV). CONTINUE: home meds unchanged.
5. fhir_search Observation discharge labs. Returns: WBC 7.2 (normalized), procalcitonin 0.15 (normalized).

Result: Full discharge summary with antibiotic course completion instructions, return precautions for fever/dyspnea, pneumococcal and influenza vaccination status check, PCP follow-up with repeat CXR in 6 weeks.

Troubleshooting

Encounter diagnosis array is empty

• Search Condition resources linked to the encounter: fhir_search Condition with encounter=[encounter-id].
• Check Encounter.reasonCode as a fallback for admission diagnosis.
• Some systems populate diagnoses only in the billing system. If no structured diagnoses are found, flag: "Discharge diagnoses require clinician input -- no structured diagnosis data linked to encounter."

MedicationStatement not available for home medication comparison

• Use the earliest MedicationRequest records (those with authoredOn before admission) as a proxy for the pre-admission medication list.
• Check if a medication reconciliation DocumentReference exists from admission: fhir_search DocumentReference with type=http://loinc.org|11503-0 (medication reconciliation note).
• Flag medications where home vs hospital comparison could not be performed.

No follow-up appointments found in FHIR

• Appointment resources may not be created until closer to discharge. Flag prominently: "No follow-up appointments found -- SCHEDULE REQUIRED per CMS/TJC requirements."
• Check CarePlan for planned follow-up activities that may not yet have corresponding Appointment resources.

Related Skills

• history-and-physical-generator - For the admission documentation this summary references
• progress-note-writer - For daily notes that inform the hospital course section
• medication-reconciliation - For detailed medication comparison at discharge
• transition-of-care-summary - For C-CDA transition of care documents sent to receiving providers