Imported from langcare/langcare-mcp-fhir (skills/core/care-coordination/discharge-planning-checklist/SKILL.md). Install upstream with npx skills add langcare/langcare-mcp-fhir --skill discharge-planning-checklist. Copyright stays with the author.

Discharge Planning Checklist

Overview

Assess discharge readiness by querying FHIR resources for pending orders, incomplete care plan tasks, unscheduled follow-ups, and unreconciled medications. Generate a structured checklist with pass/fail status for each CMS Condition of Participation discharge requirement. Calculate LACE readmission risk index. Create or update a discharge CarePlan resource with outstanding tasks.

FHIR Resources Used

Instructions

Step 1: Retrieve Current Encounter

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&status=in-progress&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|IMP"

Extract: admission date from period.start, reason for admission from reasonCode, attending provider from participant. If no in-progress inpatient encounter found, search for status=finished with most recent date.

Step 2: Check Pending ServiceRequests

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

Categorize pending requests:

• Lab orders: category.coding.code = "108252007" (SNOMED: Laboratory procedure)
• Imaging orders: category.coding.code = "363679005" (SNOMED: Imaging)
• Consult requests: category.coding.code = "11429006" (SNOMED: Consultation)
• Referrals: category.coding.code = "3457005" (SNOMED: Patient referral)

Flag any active or draft ServiceRequest as a discharge blocker.

Step 3: Check Pending Lab Results

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&status=preliminary,registered&category=laboratory"

Any Observation with status preliminary or registered indicates pending results. Flag as discharge blocker if ordered during current encounter.

Step 4: Verify Medication Reconciliation

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&encounter=[encounter-id]"

Also retrieve:

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

Compare MedicationRequest (inpatient orders) against MedicationStatement (home medications):

• Identify new medications added during admission
• Identify home medications held or discontinued
• Flag unreconciled discrepancies (medication in one list but not addressed in the other)
• Check that discharge prescriptions exist for all intended outpatient medications

Step 5: Check Follow-up Appointments

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

Verify at minimum:

• PCP follow-up within 7 days (14 days acceptable for low-risk)
• Specialist follow-up if condition warrants (e.g., cardiology after MI, surgery after procedure)
• Lab recheck appointment if indicated

Flag as incomplete if no future appointments found.

Step 6: Review CarePlan for Discharge Tasks

Tool: fhir_search
resourceType: "CarePlan"
queryParams: "patient=[patient-id]&status=active&category=http://snomed.info/sct|58000006"

SNOMED 58000006 = Discharge planning. Check activity array for incomplete tasks. If no discharge CarePlan exists, create one in Step 9.

Step 7: Check Patient Education Documentation

Tool: fhir_search
resourceType: "DocumentReference"
queryParams: "patient=[patient-id]&type=http://loinc.org|69981-9&date=ge=[admission-date]"

LOINC 69981-9 = Patient education note. Verify education documented for:

• Primary diagnosis
• New medications (purpose, dosing, side effects)
• Activity restrictions
• Warning signs requiring return to ED
• Follow-up instructions

Step 8: Check DME and Home Health Orders

Tool: fhir_search
resourceType: "DeviceRequest"
queryParams: "patient=[patient-id]&status=active,draft&encounter=[encounter-id]"

Also check for home health referrals:

Tool: fhir_search
resourceType: "ServiceRequest"
queryParams: "patient=[patient-id]&category=http://snomed.info/sct|385763009&status=active,draft"

SNOMED 385763009 = Home health care. Verify all DME and home health orders have been placed, not just drafted.

Step 9: Calculate LACE Readmission Risk Index

Gather data for LACE score calculation:

• L (Length of stay): Calculate from Encounter.period.start to today
• A (Acuity of admission): Check if admission was via ED (Encounter.hospitalization.admitSource)
• C (Comorbidities): Count via Charlson comorbidity conditions from active Conditions
• E (ED visits): Count Encounter resources with class = "EMER" in prior 6 months

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

Score interpretation: 0-4 Low risk, 5-9 Moderate risk, 10+ High risk. See references/lace-index.md for detailed scoring.

Step 10: Generate or Update Discharge CarePlan

If CarePlan exists from Step 6:

Tool: fhir_update
resourceType: "CarePlan"
id: "[careplan-id]"
resource: {
  "status": "active",
  "intent": "plan",
  "subject": { "reference": "Patient/[patient-id]" },
  "encounter": { "reference": "Encounter/[encounter-id]" },
  "category": [{ "coding": [{ "system": "http://snomed.info/sct", "code": "58000006", "display": "Discharge planning" }] }],
  "activity": [
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "Pending lab results reviewed" } },
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "Medication reconciliation completed" } },
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "Follow-up appointments scheduled" } },
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "Patient education completed" } },
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "DME ordered" } },
    { "detail": { "status": "[completed|in-progress|not-started]", "description": "Home health referral placed" } }
  ]
}

If no CarePlan exists, use fhir_create with the same payload (omit id).

Step 11: Format Output

DISCHARGE READINESS CHECKLIST
==============================
Patient: [name] | MRN: [mrn] | Admission: [date] | LOS: [days] days
LACE Score: [score] ([Low/Moderate/High] readmission risk)

[PASS] / [FAIL] Pending Labs/Imaging
  - [list pending items or "All results finalized"]

[PASS] / [FAIL] Medication Reconciliation
  - New: [count] medications added
  - Discontinued: [count] medications stopped
  - Unreconciled: [count] discrepancies

[PASS] / [FAIL] Follow-up Appointments
  - PCP: [date] with [provider] or "NOT SCHEDULED"
  - Specialist: [date] with [provider] or "NOT SCHEDULED"

[PASS] / [FAIL] Patient Education
  - [list topics documented or "NOT DOCUMENTED"]

[PASS] / [FAIL] DME Orders
  - [list items or "No DME required" or "PENDING"]

[PASS] / [FAIL] Home Health Referral
  - [status or "Not indicated" or "PENDING"]

OVERALL: [READY / NOT READY - X items require attention]

Examples

Example 1: Patient Ready for Discharge

User says: "Is patient 67890 ready for discharge?"

Actions:

1. fhir_search Encounter?patient=67890&status=in-progress&class=IMP -- returns encounter E-100, admitted 3 days ago for pneumonia
2. fhir_search ServiceRequest?patient=67890&status=active,draft&encounter=E-100 -- returns 0 (all orders completed)
3. fhir_search Observation?patient=67890&status=preliminary,registered&category=laboratory -- returns 0 (all results final)
4. fhir_search MedicationRequest?patient=67890&status=active&encounter=E-100 -- returns 3 inpatient meds
5. fhir_search MedicationStatement?patient=67890&status=active -- returns 5 home meds, all reconciled
6. fhir_search Appointment?patient=67890&status=booked&date=ge2024-01-15 -- returns PCP in 5 days, pulmonology in 14 days
7. fhir_search CarePlan?patient=67890&status=active&category=58000006 -- returns active discharge plan, all activities completed
8. fhir_search DocumentReference?patient=67890&type=69981-9 -- returns education note for pneumonia, antibiotics
9. Calculate LACE: L=3, A=1 (ED admit), C=2, E=0 -- Score: 6 (Moderate)

Result:

DISCHARGE READINESS CHECKLIST
==============================
Patient: Robert Chen | MRN: 67890 | Admission: 2024-01-12 | LOS: 3 days
LACE Score: 6 (Moderate readmission risk)

[PASS] Pending Labs/Imaging - All results finalized
[PASS] Medication Reconciliation - 3 new (levofloxacin, guaifenesin, albuterol), 0 discontinued, 0 unreconciled
[PASS] Follow-up Appointments - PCP: 2024-01-20, Pulmonology: 2024-01-29
[PASS] Patient Education - Pneumonia care, antibiotics, return precautions documented
[PASS] DME Orders - No DME required
[PASS] Home Health Referral - Not indicated

OVERALL: READY - All discharge criteria met

Example 2: Patient Not Ready -- Multiple Blockers

User says: "Run discharge checklist for patient abc-222"

Actions:

1. fhir_search Encounter -- returns E-500, admitted 7 days ago for CHF exacerbation
2. fhir_search ServiceRequest?status=active,draft -- returns 2: pending echocardiogram, pending cardiology consult
3. fhir_search Observation?status=preliminary -- returns 1: BNP result pending
4. fhir_search MedicationRequest -- returns 6 inpatient meds
5. fhir_search MedicationStatement -- returns 4 home meds, 2 unreconciled (new carvedilol, dose change on furosemide)
6. fhir_search Appointment?status=booked -- returns 0 future appointments
7. fhir_search CarePlan -- returns plan with 2/6 activities completed
8. fhir_search DocumentReference -- returns 0 education documents
9. LACE: L=7, A=1, C=4 (CHF, DM, CKD, HTN), E=2 -- Score: 14 (High)

Result:

DISCHARGE READINESS CHECKLIST
==============================
Patient: Dorothy Williams | MRN: abc-222 | Admission: 2024-01-08 | LOS: 7 days
LACE Score: 14 (High readmission risk)

[FAIL] Pending Labs/Imaging
  - Echocardiogram: ordered, not completed
  - BNP (LOINC 42637-9): result pending
  - Cardiology consult: requested, not completed

[FAIL] Medication Reconciliation
  - New: carvedilol 12.5mg BID (not yet reconciled with home list)
  - Changed: furosemide 20mg -> 40mg BID (dose change not documented)
  - 2 unreconciled discrepancies

[FAIL] Follow-up Appointments
  - PCP: NOT SCHEDULED
  - Cardiology: NOT SCHEDULED
  - Lab recheck (BMP for electrolytes): NOT SCHEDULED

[FAIL] Patient Education
  - NOT DOCUMENTED (CHF self-management, daily weights, sodium restriction, medication changes)

[PASS] DME Orders - Home scale for daily weights ordered
[FAIL] Home Health Referral - PENDING (draft order exists, not finalized)

OVERALL: NOT READY - 5 items require attention

Troubleshooting

No Inpatient Encounter Found

• Patient may be in observation status. Search with class=http://terminology.hl7.org/CodeSystem/v3-ActCode|OBSENC for observation encounters.
• Some systems use status=planned for encounters not yet started. Broaden search: status=in-progress,planned,arrived.

ServiceRequest Search Returns Orders From Prior Encounters

• Always filter by encounter=[encounter-id] to scope to current admission.
• If encounter ID is unavailable, filter by authored=ge[admission-date] to approximate.

Medication Reconciliation Shows False Discrepancies

• Some systems use MedicationRequest for both inpatient and outpatient orders. Check intent field: order = active prescription, plan = intended but not yet ordered.
• Brand vs generic name mismatches are common. Compare by RxNorm code (medicationCodeableConcept.coding where system = "http://www.nlm.nih.gov/research/umls/rxnorm") rather than display text.

Related Skills

• transition-of-care-summary -- generate the actual discharge/transfer document after checklist passes
• medication-reconciliation -- detailed medication reconciliation workflow
• follow-up-task-generator -- create Task resources for post-discharge follow-up items