follow-up-task-generator

name	follow-up-task-generator
description	Analyzes recent encounters, condition updates, and lab results to generate prioritized FHIR Task resources for required follow-ups with urgency classification and responsible party assignment. Use when user asks to "generate follow-up tasks", "what needs follow-up", "create follow-up orders", "pending action items", "task list for patient", or mentions "results that need follow-up". Do NOT use for discharge planning, care gap screening, or referral generation.
metadata	{"author":"LangCare","version":"1.0.0","mcp-server":"langcare-mcp-fhir","category":"care-coordination"}

Follow-Up Task Generator

Overview

Analyze a patient's recent clinical data -- encounters, condition changes, lab results, procedures, and medication changes -- to identify required follow-up actions. Generate FHIR Task resources for each follow-up item with appropriate urgency classification (urgent, soon, routine), responsible party assignment, and due dates based on clinical standards.

FHIR Resources Used

Resource	Purpose	Key Fields
Task	Generated follow-up tasks	status, priority, code, for, owner, requester, restriction.period, description, focus, reasonReference
Encounter	Recent visits triggering follow-up	type, period, reasonCode, class
Condition	Active/new conditions requiring monitoring	code, clinicalStatus, onsetDateTime, category
Observation	Lab results requiring follow-up	code, valueQuantity, interpretation, effectiveDateTime, referenceRange
Procedure	Recent procedures requiring post-procedure follow-up	code, performedDateTime, status
MedicationRequest	Medication changes requiring monitoring	medicationCodeableConcept, status, authoredOn, dosageInstruction
DiagnosticReport	Imaging/pathology requiring follow-up	code, conclusion, status
Practitioner	Provider assignment	name, identifier, specialty
ServiceRequest	Existing pending orders	status, code, intent

Instructions

Step 1: Retrieve Recent Encounter

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&_sort=-date&_count=3"

Identify the encounter(s) triggering follow-up generation. Extract: encounter type, date, reason, provider.

Step 2: Retrieve Abnormal Lab Results

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge=[30-days-ago]&_sort=-date"

Identify results requiring follow-up by checking:

• interpretation field: "H" (high), "L" (low), "HH" (critical high), "LL" (critical low), "A" (abnormal)
• Values outside referenceRange
• Critical values requiring immediate action (see references/task-prioritization.md)
• Results that are preliminary or need confirmation

Categorize each abnormal result:

• Critical: Requires same-day action (e.g., K+ > 6.0, Hgb < 7.0, troponin positive)
• Significant: Requires action within 1 week (e.g., new anemia, elevated creatinine trending up)
• Mild: Requires routine follow-up within 1 month (e.g., borderline lipids, mildly elevated TSH)

Step 3: Check for New or Changed Conditions

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&onset-date=ge=[30-days-ago]"

Also check for recently updated conditions:

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

New diagnoses requiring follow-up:

• New diabetes (SNOMED 44054006): HbA1c recheck in 3 months, diabetes education, ophthalmology referral within 1 year
• New hypertension (SNOMED 38341003): BP recheck in 1 month, BMP in 2-4 weeks if starting ACE/ARB
• New heart failure (SNOMED 42343007): Cardiology follow-up within 7-14 days, BMP + BNP recheck in 1-2 weeks
• New CKD diagnosis (SNOMED 709044004): Nephrology referral if stage 3b+, recheck creatinine in 3 months
• New malignancy: Oncology referral within 1-2 weeks, staging workup

Step 4: Check Recent Medication Changes

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&authoredon=ge=[30-days-ago]&status=active"

Medications requiring monitoring labs:

• ACE inhibitor/ARB started: BMP in 1-2 weeks (creatinine, potassium)
• Statin started: Lipid panel in 6-8 weeks, hepatic panel at baseline
• Warfarin started: INR in 3-5 days, then weekly until stable
• Metformin started: Renal function in 3 months
• Thyroid medication started/changed: TSH in 6-8 weeks
• Lithium started/changed: Lithium level in 5-7 days, renal/thyroid panel in 3 months
• Diuretic started/changed: BMP in 1-2 weeks
• Antibiotic course: Follow-up if symptoms not resolved (typically 48-72 hours for reassessment)
• New insulin: Glucose log review in 1 week, HbA1c in 3 months
• Anticoagulant (DOAC) started: CBC in 1 month, renal function in 3 months

Step 5: Check Post-Procedure Follow-up Needs

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&date=ge=[30-days-ago]&status=completed"

Common post-procedure follow-up intervals:

• Colonoscopy with polypectomy: Follow-up per pathology results (see references/follow-up-intervals.md)
• Surgical procedure: Wound check 7-14 days, suture/staple removal 10-14 days
• Biopsy: Results follow-up in 5-7 business days
• Joint injection: Reassessment in 4-6 weeks
• Cardiac catheterization: Follow-up in 2-4 weeks, access site check in 1 week

Step 6: Check Pending Imaging/Pathology Results

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&status=preliminary,registered&_sort=-date"

Any preliminary or pending diagnostic reports require a follow-up task to review results when finalized.

Step 7: Determine Responsible Party

Assignment logic based on task type:

• Critical lab result: Ordering provider or covering provider
• Medication monitoring lab: Prescribing provider
• Post-procedure follow-up: Performing provider/surgeon
• New diagnosis follow-up: PCP (or specialist if specialist-managed condition)
• Pending results: Ordering provider
• Referral follow-up: Referring provider (to ensure referral was completed)

If provider information is available in the Encounter or ServiceRequest:

Tool: fhir_read
resourceType: "Practitioner"
id: "[practitioner-id-from-encounter]"

Step 8: Create Task Resources

For each identified follow-up item:

Tool: fhir_create
resourceType: "Task"
resource: {
  "resourceType": "Task",
  "status": "requested",
  "intent": "order",
  "priority": "[routine|urgent|asap|stat]",
  "code": { "coding": [{ "system": "http://hl7.org/fhir/CodeSystem/task-code", "code": "fulfill", "display": "Fulfill the focal request" }] },
  "description": "[Specific follow-up action required]",
  "for": { "reference": "Patient/[patient-id]" },
  "requester": { "reference": "Practitioner/[requesting-provider-id]" },
  "owner": { "reference": "Practitioner/[responsible-provider-id]" },
  "reasonReference": { "reference": "[Condition|Observation|Procedure]/[id]" },
  "restriction": {
    "period": { "end": "[due-date-ISO-8601]" }
  },
  "input": [
    {
      "type": { "text": "follow-up-type" },
      "valueString": "[lab-recheck|appointment|imaging|referral|medication-review|result-review]"
    }
  ],
  "note": [{ "text": "[Clinical context and specific instructions]" }]
}

Priority mapping:

• stat: Critical results, same-day action required
• asap: Within 48 hours
• urgent: Within 1 week
• routine: Within 1 month

Step 9: Format Output

FOLLOW-UP TASK SUMMARY
========================
Patient: [name] | MRN: [mrn]
Generated: [timestamp]
Based on: [Encounter type] on [encounter date]
Total Tasks: [count] (Critical: [n], Urgent: [n], Routine: [n])

CRITICAL (same-day action required)
-------------------------------------
1. [Task description]
   Trigger: [what prompted this task]
   Owner: [responsible provider]
   Due: [date]
   Task ID: Task/[id]

URGENT (within 1 week)
-----------------------
1. [Task description]
   Trigger: [what prompted this task]
   Owner: [responsible provider]
   Due: [date]
   Task ID: Task/[id]

ROUTINE (within 1 month)
-------------------------
1. [Task description]
   Trigger: [what prompted this task]
   Owner: [responsible provider]
   Due: [date]
   Task ID: Task/[id]

TASKS CREATED: [total count]

Examples

Example 1: Post-Visit Follow-up for New Diagnoses and Medication Changes

User says: "Generate follow-up tasks for patient 33333 after today's visit"

Actions:

1. fhir_search Encounter?patient=33333&_sort=-date&_count=1 -- office visit today with Dr. Patel for annual physical
2. fhir_search Observation?patient=33333&category=laboratory&date=ge=2024-01-01 -- HbA1c 7.8% (H), LDL 168 (H), TSH 8.2 (H), Cr 0.9 (normal), CBC normal
3. fhir_search Condition?patient=33333&onset-date=ge=2024-01-01 -- new T2DM, new hypothyroidism diagnosed today
4. fhir_search MedicationRequest?patient=33333&authoredon=ge=2024-01-08 -- metformin 500mg BID started, levothyroxine 50mcg started, atorvastatin 20mg started
5. fhir_search Procedure?patient=33333&date=ge=2023-12-01 -- none recent
6. fhir_search DiagnosticReport?patient=33333&status=preliminary -- none pending
7. fhir_create Task x6

Result:

FOLLOW-UP TASK SUMMARY
========================
Patient: David Kim | MRN: 33333
Generated: 2024-01-08T16:30:00Z
Based on: Office visit on 2024-01-08
Total Tasks: 6 (Critical: 0, Urgent: 1, Routine: 5)

URGENT (within 1 week)
-----------------------
1. Diabetes education referral
   Trigger: New T2DM diagnosis (HbA1c 7.8%)
   Owner: Dr. Patel (PCP)
   Due: 2024-01-15
   Task ID: Task/t-001

ROUTINE (within 1 month)
-------------------------
1. Recheck BMP (creatinine, potassium) -- metformin monitoring
   Trigger: Metformin 500mg BID started 2024-01-08
   Owner: Dr. Patel (PCP)
   Due: 2024-02-08
   Task ID: Task/t-002

2. Recheck TSH -- levothyroxine monitoring
   Trigger: Levothyroxine 50mcg started 2024-01-08, TSH 8.2
   Owner: Dr. Patel (PCP)
   Due: 2024-03-05 (6-8 weeks)
   Task ID: Task/t-003

3. Recheck lipid panel -- statin monitoring
   Trigger: Atorvastatin 20mg started 2024-01-08, LDL 168
   Owner: Dr. Patel (PCP)
   Due: 2024-03-05 (6-8 weeks)
   Task ID: Task/t-004

4. Recheck HbA1c -- diabetes monitoring
   Trigger: New T2DM, HbA1c 7.8%, metformin started
   Owner: Dr. Patel (PCP)
   Due: 2024-04-08 (3 months)
   Task ID: Task/t-005

5. Ophthalmology referral -- diabetic eye screening
   Trigger: New T2DM diagnosis
   Owner: Dr. Patel (PCP)
   Due: 2025-01-08 (within 1 year of diagnosis)
   Task ID: Task/t-006

TASKS CREATED: 6

Example 2: Post-Discharge Follow-up With Critical Results

User says: "What follow-up tasks are needed for patient abc-444 who was just discharged?"

Actions:

1. fhir_search Encounter?patient=abc-444&_sort=-date&_count=1 -- discharge today from 5-day CHF admission
2. fhir_search Observation?patient=abc-444&category=laboratory&date=ge=2024-01-03 -- K+ 5.6 (H, last day), Cr 1.8 (H, up from 1.2), BNP 450 (H, down from 1200), Hgb 10.2 (L)
3. fhir_search Condition?patient=abc-444&clinical-status=active -- CHF, CKD3, T2DM, AF
4. fhir_search MedicationRequest?patient=abc-444&authoredon=ge=2024-01-03 -- carvedilol 12.5mg BID (NEW), furosemide 40mg BID (increased from 20mg), spironolactone 25mg (NEW)
5. fhir_search Procedure?patient=abc-444&date=ge=2024-01-03 -- none
6. fhir_search DiagnosticReport?patient=abc-444&status=preliminary -- echocardiogram report pending
7. fhir_create Task x7

Result:

FOLLOW-UP TASK SUMMARY
========================
Patient: Helen Martinez | MRN: abc-444
Generated: 2024-01-08T14:00:00Z
Based on: Inpatient discharge on 2024-01-08 (CHF exacerbation)
Total Tasks: 7 (Critical: 1, Urgent: 3, Routine: 3)

CRITICAL (same-day action required)
-------------------------------------
1. Review echocardiogram results when finalized
   Trigger: Echo performed 2024-01-07, report status: preliminary
   Owner: Dr. Chen (Cardiology)
   Due: 2024-01-08
   Task ID: Task/t-101

URGENT (within 1 week)
-----------------------
1. Recheck BMP (potassium, creatinine) -- diuretic and spironolactone monitoring
   Trigger: K+ 5.6 on discharge, Cr 1.8 (elevated), spironolactone + furosemide started/changed
   Owner: Dr. Rivera (PCP)
   Due: 2024-01-11 (3 days post-discharge)
   Task ID: Task/t-102

2. PCP follow-up visit -- post-discharge CHF management
   Trigger: High-risk CHF discharge, LACE score 12
   Owner: Dr. Rivera (PCP)
   Due: 2024-01-12 (within 7 days)
   Task ID: Task/t-103

3. Cardiology follow-up visit
   Trigger: CHF exacerbation, new medications, pending echo results
   Owner: Dr. Chen (Cardiology)
   Due: 2024-01-15 (within 7-14 days)
   Task ID: Task/t-104

ROUTINE (within 1 month)
-------------------------
1. Recheck CBC -- monitor anemia
   Trigger: Hgb 10.2 at discharge
   Owner: Dr. Rivera (PCP)
   Due: 2024-02-08 (1 month)
   Task ID: Task/t-105

2. Recheck BNP -- trending response to therapy
   Trigger: BNP 450 at discharge (down from 1200)
   Owner: Dr. Chen (Cardiology)
   Due: 2024-02-08 (1 month)
   Task ID: Task/t-106

3. Recheck renal function and electrolytes -- carvedilol and spironolactone monitoring
   Trigger: Cr 1.8, K+ 5.6, new spironolactone
   Owner: Dr. Rivera (PCP)
   Due: 2024-02-08 (1 month)
   Task ID: Task/t-107

TASKS CREATED: 7

Troubleshooting

No Abnormal Results Found but User Expects Follow-up Tasks

• Not all follow-up is triggered by abnormal results. Check for new medications (Step 4), new diagnoses (Step 3), and recent procedures (Step 5) which all generate monitoring tasks regardless of lab abnormalities.
• Some conditions have standing follow-up intervals. Check references/follow-up-intervals.md for chronic disease management intervals even without recent changes.

Practitioner Reference Not Available for Task Owner Assignment

• If the ordering or performing provider is not identifiable from FHIR resources, set owner to the patient's PCP (if known from Patient.generalPractitioner) or leave unassigned and note "Responsible provider to be determined -- assign to ordering provider or PCP."
• Some systems store provider assignment in the Encounter participant array. Check for type.coding.code = "ATND" (attending) or "PPRF" (primary performer).

Task Resources Not Supported by FHIR Server

• If the server does not support Task resources, output the follow-up list in the formatted text output without creating FHIR resources. Note "Task FHIR resources not created -- server does not support Task resource type."
• Consider creating ServiceRequest resources as an alternative for lab recheck orders, or CarePlan activities for appointment-based follow-ups.

Related Skills

• discharge-planning-checklist -- generates the discharge checklist that feeds into follow-up task generation
• care-gap-identifier -- identifies preventive care gaps that may generate additional routine tasks
• transition-of-care-summary -- the TOC document references follow-up tasks in the action list section
• lab-result-interpreter -- provides detailed interpretation of lab results that trigger follow-up