| name | langcare-progress-notes |
| description | 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.
|
Progress Note Writer
When to Use This Skill
Use when a clinician needs a daily inpatient progress note summarizing the patient's hospital course, overnight events, current clinical status, and updated plan.
Clinical Workflow
- Use
fhir_search to retrieve the current inpatient Encounter (calculate hospital day number)
- Use
fhir_read to retrieve Patient demographics for note header
- Use
fhir_search to pull Observation resources (vitals from last 24h with trends, overnight extremes)
- Use
fhir_search to pull Observation resources (labs from last 24h)
- Use
fhir_search to pull active MedicationRequest with changes from last 24h (compare authoredOn)
- Use
fhir_search to pull active Condition resources for problem list
- Use
fhir_search to pull pending ServiceRequest resources for outstanding orders
- Structure as: Date/HD#, Subjective (overnight events, patient-reported symptoms), Objective (vitals, I/O, labs, imaging), Assessment (updated problem list), Plan (per-problem with changes from prior day)
- Optionally persist as DocumentReference (LOINC 11506-3)
FHIR Resources
- Encounter -- Hospital day calculation from period.start
- Patient -- Demographics
- Observation -- Vitals (24h with min/max), labs (new results), I/O if available
- MedicationRequest -- Current medications with recent changes
- Condition -- Active problem list
- ServiceRequest -- Pending consults, tests
FHIR Query Examples
Pull 24h Vitals
fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=vital-signs&date=ge[24-hours-ago]&_sort=-date&_count=50")
Pull Today's Labs
fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=laboratory&date=ge[today]&_sort=-date")
Clinical Guidelines
- CMS inpatient documentation requirements
- Attending physician must document assessment/plan at least daily
- Problem-based daily progress notes preferred for complex patients
Interpretation Guide
- Hospital Day format: "HD #X" calculated from admission date
- Subjective: overnight events (nursing calls, code events, new symptoms), patient-reported status, pain score, sleep quality, diet tolerance
- Objective: vitals (current + 24h range for T, HR, RR, BP, SpO2), labs (highlight new abnormals and improving/worsening trends), I/O balance (if available), imaging results
- Assessment: numbered active problem list with brief status update per problem (improving, stable, worsening)
- Plan: per-problem updates with specific orders, medication changes, pending results, and anticipated next steps
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
