transition-of-care-summary

transition-of-care-summary is a skill for Claude Code, Codex from langcare/langcare-mcp-fhir. It costs 106 tokens per session (3,836 once invoked), scanned A, original, MIT.

A generator for transition-of-care documents, which summarize a patient’s situation when care moves between teams or settings. It organizes problems, medicines, allergies, procedures, pending results, follow-up needs, and other handoff information into a C-CDA document.

In plain words
What is it for?
Use it to create discharge or transfer summaries, prepare handoff documents, and link the completed summary to the patient’s record.
Why use it?
It reduces the chance that important information is missed during discharge, transfer, or clinical handoff.

Skill for Claude CodeCodex

Written for no agent in particular: nothing here depends on one.

Good fit Use it to create discharge or transfer summaries, prepare handoff documents, and link the completed summary to the patient’s record.

Compare 6 skills from other repositories ↓
Install with agentmods
npx agentmods add skills/langcare/langcare-mcp-fhir/transition-of-care-summary
Install

Getting it into your agent

One page per mod, every tool's command on it. A separate URL per tool would split the same page into five that compete with each other.

Any agent
npx skills add langcare/langcare-mcp-fhir --skill transition-of-care-summary
Clone the repo
git clone --depth 1 https://github.com/langcare/langcare-mcp-fhir

Made for: Claude Code, Codex.

Wrote this? Show the measurements

A badge with what this costs and how it scanned, read live from this page, so it follows the numbers instead of freezing them. Markdown for a README, HTML for a documentation site or a project page.

agentmods badge for transition-of-care-summary

README.md
[![agentmods](https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/transition-of-care-summary/github.svg)](https://agentmods.dev/skills/langcare/langcare-mcp-fhir/transition-of-care-summary)
Your own site
<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/transition-of-care-summary"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/transition-of-care-summary/github.svg" alt="Measured on agentmods" height="20"></a>

Or the 80×15 button, for a site that already has a row of RSS and ATOM ones. Only the verdict fits; the numbers stay here.

agentmods 80×15 button for transition-of-care-summary

Your own site · 80×15
<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/transition-of-care-summary"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/transition-of-care-summary.svg" alt="Reviewed on agentmods" width="80" height="20"></a>
Per session 106 Skills are progressive disclosure: only the name and description are preloaded; the body loads when the skill is used.
When invoked 3,836 The whole file, excluding the scripts and references it only reads on demand.
Security scan A 0 findings. A grade says what 26 rules found in the file — not that it is safe.
Origin original No closer match found in the catalogue.
Token cost

What it costs to keep this loaded

Counted locally with the o200k_base tokenizer, which is exact for GPT models; Claude uses its own tokenizer and its counts differ. Treat this as one consistent yardstick across the catalogue rather than a bill. Prices are per million input tokens.

ModelPer sessionOnce invoked
Fable 5.1 $0.00106 $0.03836
Opus 5 $0.00053 $0.01918
Sonnet 5 $0.00021 $0.00767
Haiku 4.5 $0.00011 $0.00384

Measured 12d ago against content hash c912922d01ad, method: parsed. Prices are Anthropic first-party input rates as of 2026-09-12, from the pricing page.

Security

Grade A, and why

transition-of-care-summary scanned grade A with 0 findings against 26 rules in 11 categories — prompt injection, anti-refusal, data exfiltration, privilege escalation, supply chain, agent snooping, system-prompt leakage, SSRF and excessive agency — measured 12d ago.

A static scan of the body, not an audit. Every finding is printed with the line that produced it so you can judge whether it matters here. A mod is markdown that instructs an agent; that is exactly why what it instructs is worth reading.

Nothing flagged

None of the 26 patterns this scan looks for appear in this file: no shell pipes, no recursive deletes, no credential paths, no hidden text, no instruction-override or anti-refusal phrasing, no agent-config snooping. That is not a guarantee, it is the absence of the things that are checkable.

skills/core/care-coordination/transition-of-care-summary/SKILL.md · 392 lines

How it starts

The opening of the file, as written. The whole thing — 392 lines — stays where its author put it; the contents beside it link to each section on GitHub.

Transition of Care Summary

Overview

Generate a comprehensive transition of care document containing all required C-CDA sections for patient handoff. Pull all relevant FHIR resources to create a complete clinical picture. Output a structured summary organized by Joint Commission TOC requirements. Create a DocumentReference FHIR resource linking to the generated summary.

FHIR Resources Used

Resource Purpose Key Fields
Patient Demographics and identifiers name, birthDate, gender, identifier, address, telecom
Encounter Current/recent encounter details status, class, period, reasonCode, participant, hospitalization
Condition Active problems and hospital diagnoses code, clinicalStatus, verificationStatus, onsetDateTime, category
MedicationRequest Discharge/current prescriptions medicationCodeableConcept, dosageInstruction, status, intent
MedicationStatement Home medication list medicationCodeableConcept, status, dosage
AllergyIntolerance Allergies and adverse reactions code, reaction, clinicalStatus, criticality
Procedure Procedures performed during stay code, performedDateTime, status, outcome
Observation Labs, vitals, functional status code, valueQuantity, effectiveDateTime, interpretation
DiagnosticReport Imaging and pathology results code, conclusion, effectiveDateTime, status
Immunization Immunization history vaccineCode, occurrenceDateTime, status
CarePlan Active care plans status, category, activity, goal
Consent Advance directives, code status category, status, provision
DocumentReference Store the generated TOC type, content, context
ServiceRequest Pending orders and referrals status, code, intent
Goal Treatment goals lifecycleStatus, description, target

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract: full legal name, DOB, age, gender, MRN, address, phone, preferred language, emergency contacts (from contact array or RelatedPerson search).

Read the full file on GitHub · 392 lines

Files

What ships with it

2 files beside SKILL.md in the same directory: the scripts, references and assets a skill reads on demand. Not counted in the per-session cost; read them before you install if any of them is executable.

Changes

What this file has done since we first saw it

Hashed on every crawl. A supply-chain change to an agent config is a question of when, not whether, so the history is kept rather than the latest state alone.

  1. 12d ago First seen · 392 lines · 106 tokens per session scan A c912922d01ad

Subscribe to this mod's changes

transition-of-care-summary is a skill published in the GitHub repository langcare/langcare-mcp-fhir (55 stars, last pushed 5mo ago), licensed MIT. It adds 106 tokens to every session and 3,836 once invoked, about $0.0005 per session on Opus 5. A static security scan graded it A with 0 findings. No closer match exists in the catalogue, so it is treated as the original; first seen 2026-08-30.

Related

Other skills, from other repositories

baoyu-youtube-transcript

A tool for downloading the written captions, subtitles, chapter information, speaker labels, and cover image from a YouTube video using its URL or ID.

JimLiu/baoyu-skills · 107 tokens

orbit-notion

Open Orbit briefing skill — selected by the Orbit pipeline when Notion is the user's only connected connector, or when the user explicitly scopes their daily digest to Notion. Pulls the past 24 hours of document edits, comments, mentions, and database row changes from the user's authenticated Notion connection and…

nexu-io/open-design · 117 tokens

instrument-data-to-allotrope

Convert laboratory instrument output files (PDF, CSV, Excel, TXT) to Allotrope Simple Model (ASM) JSON format or flattened 2D CSV. Use this skill when scientists need to standardize instrument data for LIMS systems, data lakes, or downstream analysis. Supports auto-detection of instrument types. Outputs include full…

anthropics/knowledge-work-plugins · 123 tokens

feishu

Work with Feishu or Lark bots, docs, sheets, bitables, approval flows, and OpenAPI/MCP setup without hardcoding credentials.

Hmbown/CodeWhale · 33 tokens

read

Reads URLs and PDFs by fetching source content, defaulting to concise summaries for plain read requests and clean Markdown when asked to convert, save, quote, cite, or feed downstream work. Use when users ask in any language to read, fetch, check, summarize, quote, cite, convert, or save a URL or PDF. Not for local…

tw93/Waza · 78 tokens

overleaf-sync

A two-way connection between a local paper folder and Overleaf, a web-based LaTeX editor for writing research papers. It lets you move changes between the local files and the shared Overleaf project.

wanshuiyin/Auto-claude-code-research-in-sleep · 97 tokens