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discharge-planning-checklist

Aggregate FHIR resources to identify discharge readiness risks and generate tasks.

53|12|Updated Jan 26, 2026
Search Tags:#planning#follow-up#fhir#care-coordination#discharge#lace-index#medication-reconciliation
One-click install
npx skills add https://github.com/langcare/langcare-mcp-fhir --skill discharge-planning-checklist
Or copy as Structured Prompt for Agent▼
Please help me install this Agent Skill.
Skill: discharge-planning-checklist
Source: https://github.com/langcare/langcare-mcp-fhir/tree/main/skills/core/care-coordination/discharge-planning-checklist
Command: npx skills add https://github.com/langcare/langcare-mcp-fhir --skill discharge-planning-checklist

SYSTEM DOCUMENTATION & REQUIREMENTS

💡 This Skill includes references (resource) components.

What problem does it solve?

Discharge planning is complex and error-prone. This skill consolidates patient data across encounters, orders, and documentation to provide a single, auditable readiness checklist that reduces missed tasks and readmission risk.

Core Features & Use Cases

  • Automated LACE scoring from Encounter, Conditions, and prior ED visits to flag high-risk patients.
  • Comprehensive verification of discharge elements: medication reconciliation, pending orders, follow-up appointments, patient education, DME, and home health referrals.
  • Generates or updates a Discharge CarePlan that captures tasks and status for the current admission and supports documentation for governance and continuity of care.

Quick Start

Run the discharge planning checklist for the current admission to generate a discharge plan.

Frequently Asked Questions about discharge-planning-checklist

High-intent search queries and answers about installing and using this skill.

FAQPage Schema
How do I automate discharge planning with FHIR resources?▼

Automate discharge planning by aggregating FHIR resources like ServiceRequest, Observation, and DocumentReference to generate a standardized readiness checklist and actionable tasks.

What is a LACE index score and how is it calculated for care coordination?▼

The LACE index score evaluates readmission risk by analyzing FHIR Encounter data, patient Conditions, and prior emergency department visits to flag high-risk admissions.

How do I track medication reconciliation and follow-up scheduling before patient discharge?▼

Track medication reconciliation and follow-up scheduling by generating or updating a Discharge CarePlan that verifies pending orders, follow-up appointments, and medication reconciliation status.

Does this discharge checklist handle DME and home health referrals?▼

Yes, the discharge checklist handles DME and home health referrals by extracting DeviceRequest and ServiceRequest data to verify equipment needs and home health referrals.

Can I update a FHIR CarePlan with discharge readiness tasks?▼

Yes, you can update FHIR CarePlan resources by generating or updating a Discharge CarePlan that captures tasks and statuses to support governance and continuity of care.

What are the limitations of using automated checklists for inpatient discharge readiness?▼

Automated discharge readiness checklists depend on accurate FHIR data extraction from ServiceRequest, Observation, and DocumentReference resources; incomplete source data can limit LACE scoring accuracy and task verification.

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