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