Discharge Planning Checklist

When to Use This Skill

Use when a clinician needs to verify discharge readiness by checking all CMS Condition of Participation requirements and calculating readmission risk.

Clinical Workflow

1. Use fhir_search to retrieve the current inpatient Encounter (status=in-progress, class=IMP)
2. Use fhir_search to check for pending ServiceRequest resources (active/draft labs, imaging, consults)
3. Use fhir_search to check for pending Observation results (status=preliminary/registered)
4. Use fhir_search to verify medication reconciliation: compare active MedicationRequest against MedicationStatement for discrepancies
5. Use fhir_search to check for scheduled follow-up Appointments (status=booked, date >= today)
6. Use fhir_search to check for patient education DocumentReference resources (LOINC 69981-9)
7. Use fhir_search to check for DME orders (DeviceRequest) and home health referrals (ServiceRequest)
8. Calculate LACE readmission risk index: L=length of stay, A=acuity of admission, C=comorbidities (Charlson), E=ED visits in 6 months (see references/lace-index.md)
9. Generate or update discharge CarePlan with pass/fail status for each requirement

FHIR Resources

• Encounter -- Current admission: period, class, reasonCode, admitSource
• ServiceRequest -- Pending orders: status, intent, code, category
• Observation -- Pending lab results: status
• MedicationRequest / MedicationStatement -- Medication reconciliation
• Appointment -- Follow-up scheduling: status, start, serviceType
• DocumentReference -- Patient education: type (LOINC 69981-9)
• DeviceRequest -- DME orders: status, code
• CarePlan -- Discharge plan with activities

FHIR Query Examples

Check Pending Orders

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

Check Follow-up Appointments

fhir_search(resourceType="Appointment", queryParams="patient=[patient-id]&status=booked,proposed&date=ge[today]")

Count ED Visits (6 months) for LACE

fhir_search(resourceType="Encounter", queryParams="patient=[patient-id]&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|EMER&date=ge[6-months-ago]")

Clinical Guidelines

• CMS Conditions of Participation for Discharge Planning (42 CFR 482.43)
• Joint Commission standards for discharge planning
• LACE index for readmission prediction (van Walraven et al.)

Interpretation Guide

• Present as pass/fail checklist: pending labs/imaging, medication reconciliation, follow-up appointments, patient education, DME orders, home health referral
• LACE score: 0-4 low risk, 5-9 moderate risk, >=10 high risk for 30-day readmission
• Flag any FAIL item as a discharge blocker with specific action needed
• For high LACE scores (>=10), recommend enhanced post-discharge interventions: nurse phone call within 48h, transitional care management visit within 7 days

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