langcare-mcp-fhir

Identifies care gaps for an individual patient by checking overdue preventive screenings, missing chronic disease monitoring, and unmet quality measure criteria from FHIR data. Use when asked about care gaps, overdue screenings, missing preventive care, what is this patient due for, or patient care compliance check.

Performs comprehensive discharge readiness assessment by checking pending labs, imaging, medication reconciliation, follow-up appointments, patient education, DME orders, and home health referrals. Calculates LACE readmission risk index. Use when asked to check discharge readiness, discharge checklist, is patient ready for discharge, or prepare for discharge.

Generates structured follow-up tasks from encounter data including pending results, referral tracking, medication monitoring, and screening reminders. Creates FHIR Task resources for care team tracking. Use when asked to generate follow-up tasks, create to-do list, post-visit tasks, pending follow-up items, or results management tasks.

Generates specialist referral requests by compiling relevant clinical data from FHIR resources into a structured referral package. Creates ServiceRequest resources for the referral order. Use when asked to generate a referral, specialist consult request, create a referral, or compile referral data for a specialist.

Generates a structured transition-of-care summary using the I-PASS framework for safe patient handoffs between care settings. Compiles illness severity, patient summary, action list, situation awareness, and synthesis from FHIR data. Use when asked for transition of care summary, handoff, transfer summary, or I-PASS handoff.

Calculates cardiovascular risk scores including CHA2DS2-VASc, HEART Score, ASCVD Pooled Cohort Equations, and HAS-BLED from FHIR data. Generates treatment-threshold recommendations per ACC/AHA guidelines. Use when asked to assess cardiac risk, stroke risk in AFib, HEART score, CHA2DS2-VASc, ASCVD risk, or statin candidacy.

Assesses fall risk using the Morse Fall Scale and medication-related fall risk factors from FHIR data. Identifies high-risk medications, environmental factors, and mobility impairments. Use when asked to assess fall risk, Morse fall scale, fall prevention, fall risk medications, or patient safety assessment for falls.

Assesses pneumonia severity using CURB-65 and PSI/PORT scores to guide disposition (outpatient vs inpatient vs ICU). Pulls vitals, labs, and imaging from FHIR data. Use when asked about pneumonia severity, CURB-65 score, pneumonia disposition, community-acquired pneumonia management, or PORT score calculation.

Screens patients for sepsis using qSOFA, SOFA, and SIRS criteria by pulling vitals and labs from FHIR Observation resources. Evaluates Surviving Sepsis Campaign hour-1 bundle compliance. Use when asked to screen for sepsis, check qSOFA score, SOFA score, SIRS criteria, sepsis risk, or when suspected infection with hemodynamic instability is present.

Assesses venous thromboembolism risk using Wells Criteria (DVT and PE) and Caprini Score for surgical patients. Recommends prophylaxis based on risk stratification. Use when asked about VTE risk, DVT risk, PE risk, Wells score, Caprini score, thromboprophylaxis, or blood clot prevention.

Generates comprehensive discharge summary documents from FHIR data including admission diagnosis, hospital course, procedures, discharge medications, follow-up instructions, and pending results. Use when asked to write a discharge summary, generate discharge documentation, or create a hospital discharge note.

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.

Generates structured procedure note templates from FHIR data including pre-procedure assessment, procedure details, findings, complications, and post-procedure plan. Use when asked to write a procedure note, create an operative note, document a procedure, or generate a procedural documentation template.

Generates daily inpatient progress notes from FHIR data including overnight events, current vitals, labs, I/O, medication changes, and updated assessment/plan. Use when asked to write a progress note, daily note, inpatient rounding note, or hospital day update.

Generates structured SOAP notes from FHIR encounter data including chief complaint, vitals, labs, medications, conditions, and procedures. Supports ambulatory, ED, and inpatient formats. Use when asked to write a SOAP note, generate encounter note, document this visit, create a clinic note, or mentions SOAP format.

Detects and alerts on critical laboratory values requiring immediate clinical action per CAP/CLIA thresholds. Generates structured critical value notifications with recommended interventions. Use when asked to check for critical labs, critical value alerts, panic values, stat lab review, or when monitoring for dangerous lab results.

Reviews diabetes-related laboratory results against ADA Standards of Care including HbA1c, fasting glucose, lipid panel, renal function, and urine albumin. Tracks glycemic control trends and flags overdue monitoring. Use when asked to review diabetes labs, A1c trends, diabetes panel, glycemic control, or diabetic monitoring.

Retrieves, organizes, and interprets laboratory results with clinical context including delta checks, abnormal pattern recognition, and drug-lab correlations. Use when asked to interpret labs, review lab results, explain bloodwork, check labs, lab trends, or abnormal labs. Flags critical values requiring immediate action.

Evaluates preoperative laboratory readiness by checking required labs based on procedure type, patient age, comorbidities, and ASA classification. Identifies missing or expired labs and flags abnormal results that may delay surgery. Use when asked for pre-op labs, surgical clearance labs, preoperative lab checklist, or readiness for surgery assessment.

Assesses renal function using KDIGO staging criteria from creatinine, eGFR, BUN, urine albumin, and electrolytes. Tracks CKD progression and flags medication dose adjustments needed for renal impairment. Use when asked about renal function, kidney function, CKD staging, eGFR trends, or nephrology assessment.

Screens medications against the AGS Beers Criteria for potentially inappropriate medication use in older adults (age 65+). Identifies medications to avoid, dose adjustments needed, and drug-disease interactions specific to geriatric patients. Use when asked about Beers criteria, inappropriate medications in elderly, geriatric medication review, or STOPP-START criteria.

Checks for clinically significant drug-drug interactions across active medications using CYP450 metabolism pathways, pharmacodynamic interactions, and contraindicated combinations. Use when asked to check drug interactions, medication safety check, CYP interactions, or before adding a new medication to an existing regimen.

Assesses medication adherence by analyzing prescription fill patterns from MedicationDispense resources, calculating proportion of days covered (PDC), and identifying gaps in therapy. Use when asked about medication adherence, compliance, fill history, refill gaps, PDC, or whether a patient is taking their medications as prescribed.

Performs comprehensive medication reconciliation across care transitions by comparing inpatient, outpatient, and patient-reported medication lists. Identifies discrepancies including duplicates, therapeutic duplications, dose changes, and discontinued medications. Use when asked to reconcile medications, compare med lists, admission meds, or discharge meds.

Performs opioid risk assessment by calculating morphine milligram equivalents (MME), applying Opioid Risk Tool scoring, and evaluating CDC 2022 guideline thresholds. Flags concurrent benzodiazepines, missing naloxone, and high-MME prescriptions. Use when asked to assess opioid risk, calculate MME, check opioid safety, or review opioid prescriptions.

Retrieves and organizes allergy and adverse reaction data from FHIR AllergyIntolerance resources. Cross-references against active medications for contraindications. Use when asked to review allergies, check for drug allergies, allergy summary, adverse reactions, or verify allergy documentation before prescribing.

Generates a comprehensive clinical summary (CCD-style) from FHIR resources including problems, medications, allergies, labs, vitals, procedures, and immunizations. Use when asked for chart review, clinical summary, patient overview, CCD, or comprehensive patient snapshot before a visit or consult.

Retrieves and formats a complete patient demographic summary from FHIR Patient, RelatedPerson, and Coverage resources. Use when asked to pull demographics, get patient info, show patient details, who is this patient, emergency contacts, or insurance info. Flags missing critical data elements that may affect care delivery.

Retrieves and analyzes insurance coverage from FHIR Coverage and Organization resources including coordination of benefits, coverage gaps, and eligibility details. Use when asked about insurance info, coverage details, benefits check, coordination of benefits, coverage verification, or payer information.

Audits the patient problem list for accuracy by cross-referencing active Conditions against medications, labs, and encounter diagnoses. Identifies missing diagnoses, resolved conditions still marked active, and coding discrepancies. Use when asked to review problem list, audit diagnoses, clean up problem list, or verify active conditions.

Queries and reports on chronic disease registries including diabetes, HTN, CHF, COPD, CKD, and asthma populations with severity distribution, control rates, and patients needing intervention. Use when asked about disease registries, chronic disease population, diabetes registry, HTN registry, disease-specific panel report, or population with specific condition.

Checks patient immunization status against CDC/ACIP recommended schedules by age group and risk factors. Identifies missing or overdue vaccinations and generates recommendations. Use when asked to check immunization status, vaccine history, immunizations due, vaccination compliance, or what vaccines does this patient need.

Generates a patient panel overview with aggregate statistics including panel size, demographics, disease prevalence, risk stratification, and utilization patterns from FHIR resources. Use when asked for panel overview, patient panel stats, practice summary, panel demographics, or caseload analysis.

Generates a comprehensive preventive care compliance report for a patient or population based on USPSTF A/B grade recommendations, ACS screening guidelines, and ACIP immunization schedules. Identifies overdue screenings with age/sex/risk-appropriate criteria. Use when asked about preventive care compliance, wellness checkup, annual screening status, or health maintenance.

Calculates HEDIS-style quality measures from FHIR data including denominator/numerator/exclusion logic, measure rates, gap-to-goal analysis, and non-compliant patient identification. Use when asked to calculate quality measures, HEDIS rates, quality dashboard, star rating, measure compliance, or CMS quality scores.

Performs comprehensive chronic pain management review including pain assessment scores, current analgesic regimen, functional status, opioid risk evaluation, and multimodal therapy assessment per CDC 2022 guidelines. Use when asked about chronic pain review, pain management assessment, non-opioid pain therapy, multimodal pain plan, or pain clinic evaluation.

Performs mental health screening using PHQ-9 (depression), GAD-7 (anxiety), AUDIT-C (alcohol use), and Columbia Suicide Severity Rating Scale from FHIR Observation data. Tracks symptom trends and treatment response. Use when asked for mental health screening, depression assessment, PHQ-9 score, GAD-7 score, anxiety assessment, or behavioral health evaluation.

Compiles oncology treatment timeline from FHIR data including cancer staging (TNM), treatment history (chemo, radiation, surgery), lab trends (tumor markers, CBC), and response assessment (RECIST criteria). Use when asked about oncology timeline, cancer treatment history, tumor staging, treatment response, or cancer care summary.

Assesses pediatric growth by plotting weight, height/length, head circumference, and BMI against WHO (0-2 years) and CDC (2-20 years) growth chart percentiles. Flags growth faltering, obesity, and failure to thrive. Use when asked about pediatric growth, growth chart, growth percentiles, FTT, childhood obesity, or weight-for-age.

Performs structured prenatal visit assessment organized by trimester with ACOG guideline alignment. Tracks gestational age, weight gain, BP trends, fetal assessment, trimester-specific labs, and risk factors. Use when asked to review prenatal visit, prenatal assessment, OB visit, pregnancy checkup, trimester labs, or gestational age evaluation.