| name | langcare-history-physical |
| description | Generates a comprehensive History and Physical (H&P) document from FHIR resources for hospital admissions or initial consultations. Includes HPI, PMH, surgical history, medications, allergies, social/family history, ROS, physical exam, labs, assessment, and plan. Use when asked to write an H&P, admission note, history and physical, or initial consultation note.
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History and Physical Generator
When to Use This Skill
Use when a clinician needs a comprehensive H&P document for hospital admission or initial specialist consultation.
Clinical Workflow
- Use
fhir_read to retrieve Patient demographics, emergency contacts
- Use
fhir_search to retrieve the admitting Encounter (reasonCode, class=IMP)
- Use
fhir_search to pull all Condition resources: active problems (PMH), encounter diagnoses (admitting diagnosis)
- Use
fhir_search to pull Procedure resources for surgical history
- Use
fhir_search to pull active MedicationRequest and MedicationStatement for home medications
- Use
fhir_search to pull AllergyIntolerance resources
- Use
fhir_search to pull Observation resources: social history (category=social-history), vitals, labs
- Use
fhir_search to pull FamilyMemberHistory resources for family history
- Assemble H&P in standard format: CC, HPI, PMH, PSH, Medications, Allergies, Social Hx, Family Hx, ROS, Physical Exam, Labs/Studies, Assessment, Plan
- Optionally use
fhir_create to persist as DocumentReference (LOINC 34117-2)
FHIR Resources
- Encounter -- Admission context
- Patient -- Demographics
- Condition -- Active problems (PMH) and admitting diagnoses
- Procedure -- Surgical history
- MedicationRequest / MedicationStatement -- Medications
- AllergyIntolerance -- Allergies
- Observation -- Social history (smoking, alcohol, drugs), vitals, labs
- FamilyMemberHistory -- Family medical history
- DocumentReference -- Output: H&P document
FHIR Query Examples
Pull Surgical History
fhir_search(resourceType="Procedure", queryParams="patient=[patient-id]&_sort=-date&_count=50")
Pull Social History
fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=social-history")
Pull Family History
fhir_search(resourceType="FamilyMemberHistory", queryParams="patient=[patient-id]")
Clinical Guidelines
- CMS H&P documentation requirements for hospital admissions
- Joint Commission medical record standards
- Specialty-specific H&P templates (surgical, medical, psychiatric)
Interpretation Guide
- Structure sections in standard medical H&P order
- PMH: organize by system (cardiovascular, endocrine, neurologic, etc.)
- PSH: list procedures with approximate dates
- Social history: include tobacco (pack-years), alcohol (drinks/week), drug use, occupation, living situation, advance directives
- Family history: organize by first-degree relative with conditions and age of onset/death
- Assessment: primary admitting diagnosis first, then secondary diagnoses numbered by priority
- Plan: per-problem approach with immediate orders, workup plan, and anticipated hospital course
Safety
- Never fabricate clinical data -- only report what FHIR returns
- Flag critical/abnormal values immediately
- Scope all FHIR queries to the authenticated patient
- Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
- Present data in clinician-friendly format with reference ranges
