| name | langcare-procedure-notes |
| description | 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.
|
Procedure Note Template
When to Use This Skill
Use when a clinician needs a structured procedure note populated with patient context from FHIR resources.
Clinical Workflow
- Use
fhir_read to retrieve Patient demographics and allergies
- Use
fhir_search to pull the Procedure resource for the completed procedure (code, performedDateTime, outcome)
- Use
fhir_search to pull pre-procedure Observation resources (vitals, relevant labs, coagulation studies)
- Use
fhir_search to pull active Condition resources for relevant comorbidities and procedure indication
- Use
fhir_search to pull MedicationRequest for anesthesia/sedation medications administered
- Assemble procedure note: patient identification, procedure name/CPT, indication, consent status, anesthesia type, pre-procedure assessment, procedure description (technique, findings), specimens collected, complications, estimated blood loss, post-procedure condition, and plan
- Optionally use
fhir_create to persist as DocumentReference (LOINC 28570-0 for procedure note)
FHIR Resources
- Patient -- Demographics, allergies
- Procedure -- Procedure details: code (CPT/SNOMED), status, performedDateTime, outcome, complication
- Observation -- Pre-procedure vitals and labs
- Condition -- Procedure indication and comorbidities
- MedicationRequest / MedicationAdministration -- Anesthesia, sedation, antibiotics
- DocumentReference -- Output: procedure note
FHIR Query Examples
Pull Procedure Details
fhir_read(resourceType="Procedure", id="[procedure-id]")
Pull Pre-Procedure Labs
fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=laboratory&date=ge[procedure-date-minus-7d]&date=le[procedure-date]&_sort=-date")
Clinical Guidelines
- CMS operative report documentation requirements
- Joint Commission immediate post-procedure documentation standards
- Specialty-specific procedure note elements (ACS, ASGE, ACC)
Interpretation Guide
- Structure: Date/Time, Patient ID, Procedure (name + CPT code), Surgeon/Proceduralist, Assistant(s), Anesthesia (type + provider), Indication, Consent (confirmed), Pre-procedure assessment (vitals, relevant labs), Technique (step-by-step), Findings, Specimens (sent to pathology), Complications (none or describe), EBL, Post-procedure condition (stable/ICU/etc.), Post-procedure orders, Follow-up plan
- For endoscopic procedures: include scope type, insertion/withdrawal times, visualization quality, biopsy sites
- For surgical procedures: include incision type, exposure, key operative findings, closure method, drain placement
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
