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

Resource	Purpose	Key Fields
ServiceRequest	Pending labs, imaging, consults	status, intent, code, authoredOn
CarePlan	Discharge plan with tasks	status, intent, activity, category
Appointment	Scheduled follow-ups	status, serviceType, start, participant
MedicationRequest	Active prescriptions for reconciliation	status, medicationCodeableConcept, dosageInstruction
MedicationStatement	Patient-reported medications	status, medicationCodeableConcept
Encounter	Current admission details	status, class, period, reasonCode
Condition	Active problems for discharge summary	clinicalStatus, code, onsetDateTime
Procedure	Completed procedures during stay	status, code, performedDateTime
Observation	Pending lab results	status, code, valueQuantity
DocumentReference	Patient education materials	type, status, content
DeviceRequest	DME orders	status, codeCodeableConcept, intent

Instructions

Step 1: Retrieve Current Encounter

code

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

code

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

code

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

code

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

Also retrieve:

code

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

code

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

code

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

code

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

code

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

Also check for home health referrals:

code

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

code

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:

code

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

code

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:

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

Result:

code

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:

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

Result:

code

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