transition-of-care-summary

Name: transition-of-care-summary
Availability: InStock
Author: LangCare

Aggregate FHIR patient data into a structured I-PASS Transition of Care document.

53|12|Updated Jan 26, 2026

Search Tags:#handoff #toc #fhir #care-coordination #transition-of-care #document-reference #ipass

Ready to run

npx skills add https://github.com/langcare/langcare-mcp-fhir --skill transition-of-care-summary

💬 Prompt for ChatGPT / Claude Chat▼

Please help me install this Agent Skill.
Skill: transition-of-care-summary
Source: https://github.com/langcare/langcare-mcp-fhir/tree/main/skills/core/care-coordination/transition-of-care-summary
Command: npx skills add https://github.com/langcare/langcare-mcp-fhir --skill transition-of-care-summary

SYSTEM DOCUMENTATION & REQUIREMENTS

💡 This Skill includes references (resource) components.

What problem does it solve?

Automates the creation of a C-CDA compliant Transition of Care (TOC) document by aggregating patient data from FHIR resources into a structured handoff narrative and artifacts.

Core Features & Use Cases

Integrates demographics, encounters, problems, medications, allergies, procedures, results, immunizations, advance directives, and pending orders to build a comprehensive TOC.
Formats output according to I-PASS handoff framework for clear communication and risk reduction during patient transfers.
Produces a DocumentReference entry linking to the generated TOC and references the relevant Encounter for traceability.

Quick Start

Trigger the transition-of-care-summary process with a patient ID and encounter ID to generate and export the TOC.

Frequently Asked Questions about transition-of-care-summary

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

FAQPage Schema

How do I generate a transition of care summary from FHIR resources?▼

Generate a transition of care summary by triggering the process with a patient ID and encounter ID, which aggregates FHIR resources like Condition, MedicationRequest, and Procedure into a structured TOC document.

What is the I-PASS handoff framework for transition of care documents?▼

The I-PASS handoff framework structures transition of care documents by organizing clinical data into standardized sections, ensuring clear communication and risk reduction during patient transfers between facilities or PCPs.

Can I use FHIR resources to build a C-CDA compliant transition of care document?▼

Yes, you can build a C-CDA compliant transition of care document by aggregating patient data from FHIR resources, including demographics, encounters, problems, medications, allergies, and procedures into a structured handoff narrative.

Does the transition of care summary include active problems, meds, and follow-up care plans?▼

Yes, the transition of care summary aggregates active problems, meds, allergies, results, procedures, immunizations, advance directives, and pending orders to build a comprehensive handoff document.

What's the best way to trace a generated TOC document back to a patient encounter?▼

Trace a generated TOC document by producing a DocumentReference entry that links to the structured handoff document and references the relevant patient encounter ID for traceability.