Transition of Care Summary (Pediatric Endocrinology to Adult Care)

Patient Name: [Full legal name] (Include preferred name if different)

DOB / MRN: [Date of birth] / [Medical record number]

Primary Diagnosis: [Primary endocrine diagnosis]

Pediatric Endocrinology: [Clinic name] — [Primary pediatric endocrinologist name, credentials]

Receiving Adult Provider: [Adult endocrinologist name, credentials — Clinic name / To be determined]

Date of Summary: [Date]

Reason for Transfer: [Age-based transition / Relocation / Insurance change / Other: specify]

Language / Interpreter Needs: [Preferred language; interpreter needs and modality if applicable]

Best Contact Method: [Phone / Portal / Email / Other] (Include preferred time window if documented)

Emergency Contact: [Name, relationship, phone]

Executive Transition Synopsis

• [Patient identifier and transfer trigger summary]
• [Primary endocrine diagnoses and key comorbidities impacting endocrine care]
• [Current clinical stability: Stable / Recent decompensation within (timeframe) / High-risk instability]
• [Most important safety risks requiring attention at handoff] (e.g., steroid dependence with stress dosing, severe hypoglycemia or unawareness, recurrent DKA, aortic dilation; if unknown, write "Unknown—requires verification" and add to Action List)
• [Current regimen headline] (e.g., "Automated insulin delivery pump + real-time CGM" or "Hydrocortisone with stress-dose protocol"; do not infer devices or medications)
• [Top 1–3 time-sensitive pending items with owner]
• [Recent severe events with dates] (DKA, severe hypoglycemia, adrenal crisis; if unknown, state "Unknown—requires verification" and add to Action List)

Transition Logistics

• Last pediatric endocrinology visit: [Date]
• First adult endocrinology appointment: [Date / Not yet scheduled] (If not scheduled, include referral status)
• PCP status: [Established with name/clinic / Needs referral] — Verified: [Date]
• Insurance status: [Plan name] (Note expected changes and effective date; include PA requirements if relevant)
• Records transfer: [Documents sent, recipient, date, method]
• Patient readiness: [Independent / Needs assistance] — [Device management and sick-day plan understanding; date last reviewed]

Active Problem List

• [Endocrine diagnosis] — Onset: [Month/Year] — Status: [Active / Resolved / Historical]
• [Additional endocrine diagnosis] — Onset: [Month/Year] — Status: [Active / Resolved / Historical]
• [Major comorbidity] — Onset: [Month/Year] — Status: [Active / Resolved / Historical]
• [Relevant complication] — Onset: [Month/Year] — Status: [Active / Resolved / Historical]

(List endocrine diagnoses first, then comorbidities, then complications. Include behavioral health diagnoses only if directly affecting care coordination or safety.)

Condition-Specific Summaries

(Create one subsection per major endocrine condition. Order by severity/risk rather than chronology.)

[Condition Name]

Diagnosis and etiology: [Date of diagnosis]; [Diagnostic basis: labs/imaging/genetics]; [Etiology: autoimmune / congenital / tumor-related / iatrogenic / idiopathic]

Clinical course: [Major hospitalizations, surgeries, crises with dates]; [Prior therapies tried and reasons discontinued]

Current status and regimen: [Symptom control and functional status]; [Complete medication list with dose/route/frequency] (For diabetes technology: pump make/model, algorithm mode, insulin type, CGM make/model, alert thresholds; if unknown, write "Unknown—requires verification" and add to Action List)

Device settings (diabetes only):

• Basal rates: [Time blocks and units/hr]
• Insulin-to-carbohydrate ratios: [Time blocks and g/unit]
• Correction factors: [Time blocks and mg/dL per unit]
• Glucose targets: [Time blocks and mg/dL]
• Active insulin time: [Hours]
• Max bolus: [Units] (Include if clinically relevant)

(Never infer or approximate device settings. If unavailable, write: "Device settings not available in records—requires upload at first adult visit" and add to Action List.)

Recent monitoring:

• [Key labs with dates]: [At goal / Borderline / Abnormal—see plan]
• [Imaging with dates]: [Brief interpretation]
• [For diabetes: Last two A1c values with dates; CGM summary with TIR, time below range, and data range dates if available]

Complications and safety risks: [Current complications]; [High-risk predictors]; [Safety plans: crisis dosing, DKA sick-day rules, glucagon availability] (If unknown, write "Unknown—requires verification" and add to Action List)

Pending items:

• [Task] — Owner: [Adult Endo / PCP / Patient / Care Coordinator] — Due: [Date/Timeframe]

Condition-specific surveillance (include when applicable):

• Turner syndrome: [Karyotype; cardiovascular imaging dates and aortic status; metabolic/renal/audiology/autoimmune screening; fertility counseling status]
• Pituitary disorders: [Axis-by-axis status; replacement therapies; last MRI date/result; stress-dose plan if adrenal insufficient]
• Gender-affirming care: [Preferred name/pronouns; puberty blocker history; hormone regimen; fertility preservation status; bone health monitoring]
• CAH/Adrenal insufficiency: [Daily glucocorticoid/mineralocorticoid regimen; stress-dose protocol; emergency injection availability; prior crisis history with dates/triggers]

Allergies and Safety Alerts

• Medication allergies: [Drug — Reaction type] (If verified none, write "No known drug allergies (NKDA)"; if not verified, write "Allergy status not verified" and add to Action List)
• Device/material allergies: [Adhesives / Latex / Other — Reaction] (If unknown, state "Unknown—requires verification")
• Critical safety flags: [Adrenal insufficiency with stress-dose protocol status / Severe hypoglycemia or hypoglycemia unawareness / Recurrent DKA / Aortic dilation / High thrombotic risk / Other do-not-miss alerts] (Include date of last severe event; if unknown, state "Unknown—requires verification")

Psychosocial and Transition Factors

• Living situation: [Family home / Dorm / Independent / Other] — [Location]
• Access barriers: [Cost / Transportation / Pharmacy / Technology access; mitigations in place]
• Mental health supports: [Brief summary if pertinent to care access or safety]
• Self-management skills: [Scheduling / Refills / Sick-day actions / Device troubleshooting] — [Independent / Needs assistance in specific areas]
• Support persons: [Names/roles; level and type of involvement authorized by patient]

Action List

1. [Task description] — Owner: [Adult Endo / PCP / Patient / Care Coordinator] — Due: [Date/Timeframe]
2. [Task description] — Owner: [Role] — Due: [Date/Timeframe]
3. [Task description] — Owner: [Role] — Due: [Date/Timeframe]

(Every safety-critical unknown noted above must appear here with clear ownership and timeframe.)

Care Team Directory

• Pediatric Endocrinologist: [Name, credentials] — [Clinic] — [Contact]
• Diabetes Educator: [Name] — [Clinic] — [Contact]
• Dietitian: [Name] — [Clinic] — [Contact]
• Primary Care Provider: [Name, credentials] — [Clinic] — [Contact]
• Key Specialists: [Name, specialty] — [Clinic] — [Contact]
• Receiving Adult Endocrinology: [Name, credentials] — [Clinic] — [Contact / To be determined]

Attachments

• Device downloads and settings export: [Date range] — [Attached / Sent to (clinic) on (date) / Not available]
• Growth charts: [Attached / Not applicable]
• Imaging reports (MRI/Echo/DXA): [Modality and date] — [Attached / Requested / Not available]
• Genetic test or karyotype results: [Test name/date] — [Attached / Not available]
• Emergency care plans: [Sick-day rules / Adrenal crisis plan / Glucagon instructions] — [Attached / Requested]
• Immunization record: [Attached / Not attached]

(Do not infer diagnoses, medication doses, device presence, or settings. Clearly distinguish documented records from patient-reported information. Use "Unknown—requires verification" for safety-critical fields and add corresponding items to the Action List.)