This Section describes the expected capabilities of the PACIO Transitions of Care (TOC) Server actor which is responsible for providing responses to the queries submitted by the TOC Requestors.

The TOC information is conveyed via a Bundle.

This profile defines constraints that represent common administrative and demographic concepts for transitions of care information used in US Realm clinical documents.

This value set includes those LOINC terms that are used by the DEL.

This value set includes those LOINC terms that are defined to be answered by LOINC answer list LL5571-6. Ideally, this could be intentionally defined as terms where the answer-list property is 'LL5571-6', however at publication time, this property is not supported by the FHIR terminology server at tx.fhir.org.

This value set includes those LOINC terms that included in the DEL which are defined to be answered by LOINC answer list LL5571-6.

Allergies for fictional patient Betsy Smith-Johnson.

Anemia Diagnosis for fictional patient Betsy Smith-Johnson.

Constipation Diagnosis for fictional patient Betsy Smith-Johnson.

Depression Diagnosis for fictional patient Betsy Smith-Johnson.

Diabetes Diagnosis for fictional patient Betsy Smith-Johnson.

Minimum Data Set (MDS) Discharge Assessment - Lower body dressing for fictional patient Betsy Smith-Johnson.

Minimum Data Set (MDS) Discharge Assessment - Lying to sitting on side of bed for fictional patient Betsy Smith-Johnson.

Minimum Data Set (MDS) Discharge Assessment - Sit to stand for fictional patient Betsy Smith-Johnson.

Minimum Data Set (MDS) Discharge Assessment - Upper body dressing for fictional patient Betsy Smith-Johnson.

Minimum Data Set (MDS) Discharge Assessment - Walk 50 feet with 2 turns for fictional patient Betsy Smith-Johnson.

Discharge Care Plan for fictional patient Betsy Smith-Johnson.

Discharge Service Request for Occupational Therapy referral for fictional patient Betsy Smith-Johnson.

Discharge Service Request for physical therapy referral for fictional patient Betsy Smith-Johnson.

Discharge Service Request for blood chemistry procedure for fictional patient Betsy Smith-Johnson.

Discharge Service Request for call order for fictional patient Betsy Smith-Johnson.

Discharge Service Request for complete blood count for fictional patient Betsy Smith-Johnson.

Discharge Service Request for Speech Language Pathologist referral for fictional patient Betsy Smith-Johnson.

Discharge Service Request for decreased protein and/or protein derivative diet for fictional patient Betsy Smith-Johnson.

Discharge Service Request for reduced salt diet for fictional patient Betsy Smith-Johnson.

Information about fictional practitioner Dr. Anita Chu.

Information about fictional practitioner Dr. Gerald Park.

Information about fictional practitioner Dr. Jen Cadbury.

Information about fictional practitioner Dr. Nura Mekel.

Information about fictional practitioner Dr. Phil Chekhov.

Information about fictional practitioner Dr. Tracy Count.

Dressing Concerns for fictional patient Betsy Smith-Johnson.

Home Health encounter for Betsy Smith-Johnson

Information about the Everyday Community Pharmacy Organization.

Information about the Happy Nursing Facility Organization.

Heart Disease Diagnosis for fictional patient Betsy Smith-Johnson.

Hemiparesis Diagnosis for fictional patient Betsy Smith-Johnson.

Home medication list for Betsy Smith-Johnson

hyperlipidemia Diagnosis for fictional patient Betsy Smith-Johnson.

Hypertension Diagnosis for fictional patient Betsy Smith-Johnson.

Kidney Disease Diagnosis for fictional patient Betsy Smith-Johnson.

Location of Michigan Primary Health Care Associates.

Location of the Everyday Community Pharmacy.

Location of the Happy Nursing Facility.

Location of the Neuro Care Inc. facility.

Location of the Not Every Day Contract Pharmacy.

Medication request for Acetaminophen 650 MG Oral Tablet for Betsy Smith-Johnson to treat Osteoarthritis

Medication request for Atorvastatin 40 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia

Medication request for Carvedilol 6.25 MG Oral Tablet for Betsy Smith-Johnson to treat Hypertension

Medication request for Ferrous sulfate 325 MG (iron 65 MG) Oral Tablet for Betsy Smith-Johnson to treat Anemia

Medication request for Furosemide 20 MG Oral Tablet for Betsy Smith-Johnson to treat chronic kidney disease

Medication request for Glipizide 2.5 MG Extended Release Oral Tablet for Betsy Smith-Johnson to treat Diabetes

Medication request for Rosuvastatin calcium 5 MG Oral Tablet for Betsy Smith-Johnson to treat Osteopenia

Medication request for Sertraline 25 MG Oral Tablet for Betsy Smith-Johnson to treat Depressive disorder

Medication statement for Acetaminophen 650 MG Oral Tablet for Betsy Smith-Johnson to treat Osteoarthritis

Medication statement for Atorvastatin 40 MG Oral Tablet for Betsy Smith-Johnson to treat Hyperlipidemia

Medication statement for Carvedilol 6.25 MG Oral Tablet for Betsy Smith-Johnson to treat Hypertension

Medication statement for Ferrous sulfate 325 MG (iron 65 MG) Oral Tablet for Betsy Smith-Johnson to treat Anemia

Medication statement for Furosemide 20 MG Oral Tablet for Betsy Smith-Johnson to treat chronic kidney disease

Medication statement for Glipizide 2.5 MG Extended Release Oral Tablet for Betsy Smith-Johnson to treat Diabetes

Medication statement for Rosuvastatin calcium 5 MG Oral Tablet for Betsy Smith-Johnson to treat Osteopenia

Medication statement for Sertraline 25 MG Oral Tablet for Betsy Smith-Johnson to treat Depressive disorder

Information about the Michigan Primary Health Care Associates Organization.

Nausea and vomiting for fictional patient Betsy Smith-Johnson.

Information about the Neuro Care Inc. Organization.

Neuropathy Diagnosis for fictional patient Betsy Smith-Johnson.

Information about the Not Every Day Contract Pharmacy Organization.

Minimum Data Set (MDS) Nursing Home Discharge Assessment Questions - Mobility Part 1 for fictional patient Betsy Smith-Johnson.

Occupational Therapy Decondition problem list for fictional patient Betsy Smith-Johnson.

Occupational Therapy Right Weakness problem list for fictional patient Betsy Smith-Johnson.

Basic information for fictional patient Betsy Smith-Johnson.

Dr. Anita Chu is a fictional Internal Medicine Physician at Michigan Primary Health Care Associates.

Dr. Gerald Park is a fictional Geriatric Medicine Physician at the Happy Nursing Facility.

Dr. Jen Cadbury is a fictional Internal Medicine Physician at Neuro Care Inc.

Dr. Nura Mekel is a fictional Internal Medicine Physician at Neuro Care Inc.

Dr. Phil Chekhov is a Pharmacist at Everyday Community Pharmacy.

Dr. Tracy Count is a fictional Pharmacist at Not Every Day Contract Pharmacy.

Service Request to follow up with PCP for fictional patient Betsy Smith-Johnson.

Stroke Diagnosis for fictional patient Betsy Smith-Johnson.

Example Transition of Care bundle for fictional patient Betsy Smith-Johnson.

Transitions of Care Clinical Document for fictional patient Betsy Smith-Johnson.

Undressing Concern for fictional patient Betsy Smith-Johnson.