Generates comprehensive discharge summaries per CMS and Joint Commission requirements from FHIR data including admission and discharge diagnoses, hospital course, procedures, discharge medications with changes, follow-up, and patient instructions. Use when user asks to "write a discharge summary", "create DC summary", "discharge documentation", mentions "discharge paperwork", "transition of care document", or needs discharge documentation. Do NOT use for admission H&P, daily progress notes, outpatient visit notes, or transfer summaries.
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.
| Resource | Purpose | Key Fields |
|---|---|---|
| Encounter | Admission/discharge context, LOS | period, reasonCode, hospitalization, diagnosis |
| Patient | Demographics, language preference | name, birthDate, gender, communication |
| Condition | Admission dx, discharge dx, active problems | code, clinicalStatus, category, encounter |
| Procedure | Procedures during hospitalization | code, performedDateTime, outcome, report |
| MedicationRequest | Discharge medications vs admission meds | medicationCodeableConcept, status, intent, authoredOn, dosageInstruction |
| MedicationStatement | Pre-admission home medication list | medicationCodeableConcept, dosage, status |
| AllergyIntolerance | Allergy list for summary | code, reaction, clinicalStatus |
| DiagnosticReport | Significant findings, pathology | code, conclusion, effectiveDateTime |
| Observation | Key labs at discharge, vitals | code, value[x], effectiveDateTime |
| CarePlan | Follow-up plans, discharge instructions | activity, description, period |
| Appointment | Follow-up appointments scheduled | status, serviceType, start, participant |
| DocumentReference | Persist the discharge summary | type, content, context |
Tool: fhir_read
resourceType: "Encounter"