# Langcare Langcare MCP Fhir Problem List Review > Problem List Review - Skill: `tomevault-io/langcare-langcare-mcp-fhir-problem-list-review` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-problem-list-review` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-problem-list-review/raw - Safety review: pending (external: skill-scanner PASS, skillspector PASS) - Works with: Claude Code, Claude.ai, OpenAI Codex - Category: AI & ML - Author: tomevault-io (https://skillmd.com/u/tomevault-io) - Updated: 2026-09-17 - Page: https://skillmd.com/skills/tomevault-io/langcare-langcare-mcp-fhir-problem-list-review --- # Problem List Review ## Overview Perform a structured audit of the active problem list by pulling Condition resources and cross-referencing with MedicationRequests, recent Encounters, and Observations. Identify clinical discrepancies: conditions without active treatment, resolved conditions still listed as active, medications implying undocumented conditions, and ICD-10 coding specificity opportunities. Output actionable findings for clinical review. ## FHIR Resources Used | Resource | Purpose | Search Parameters | |----------|---------|-------------------| | Condition | Active problem list | patient, clinical-status | | MedicationRequest | Cross-reference treatments | patient, status=active | | Encounter | Recent visit context | patient, date | | Observation | Lab correlation | patient, category=laboratory, code | ## Instructions ### Step 1: Pull All Conditions ``` Tool: fhir_search resourceType: "Condition" queryParams: "patient=[patient-id]" ``` Retrieve all conditions regardless of status. Categorize each by: - `clinicalStatus`: active, recurrence, relapse, inactive, remission, resolved - `verificationStatus`: confirmed, unconfirmed, provisional, differential, refuted, entered-in-error - `category`: problem-list-item, encounter-diagnosis, health-concern - `code.coding`: Extract SNOMED CT code and ICD-10-CM code if present Build two lists: 1. **Active conditions** (clinicalStatus = active, recurrence, or relapse) 2. **Inactive/resolved conditions** (clinicalStatus = inactive, remission, or resolved) ### Step 2: Pull Active Medications ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active" ``` For each medication, extract: - Drug name and RxNorm code from `medicationCodeableConcept` - Drug class (infer from name suffix or RxNorm hierarchy) - Dosage from `dosageInstruction` ### Step 3: Pull Recent Encounters (Last 12 Months) ``` Tool: fhir_search resourceType: "Encounter" queryParams: "patient=[patient-id]&date=ge[12-months-ago]&_sort=-date" ``` Extract encounter diagnoses from `reasonCode` or associated `Condition` references with `category` = encounter-diagnosis. ### Step 4: Cross-Reference Medications Against Problems For each active medication, check if a corresponding condition exists on the active problem list. Use the medication-condition mapping reference. **Flag Type A -- Medication Without Matching Condition (Implied Diagnosis Missing):** | Medication / Class | Implied Condition | Check Problem List For | |--------------------|-------------------|----------------------| | Metformin, glipizide, insulin | Type 2 Diabetes Mellitus | SNOMED 44054006 or ICD-10 E11.x | | Lisinopril, losartan, amlodipine | Hypertension | SNOMED 59621000 or ICD-10 I10 | | Atorvastatin, rosuvastatin | Hyperlipidemia | SNOMED 55822004 or ICD-10 E78.x | | Levothyroxine | Hypothyroidism | SNOMED 40930008 or ICD-10 E03.x | | Albuterol, fluticasone inhaler | Asthma or COPD | SNOMED 195967001 or 13645005 | | Sertraline, fluoxetine, escitalopram | Depression or Anxiety | SNOMED 35489007 or 197480006 | | Omeprazole, pantoprazole | GERD | SNOMED 235595009 or ICD-10 K21.0 | | Warfarin, apixaban, rivaroxaban | A-fib, DVT/PE, or valve condition | SNOMED 49436004 | | Gabapentin, pregabalin | Neuropathy, seizure disorder, or chronic pain | SNOMED 386033004 | | Methotrexate | Rheumatoid arthritis or psoriasis | SNOMED 69896004 | If medication is present but no matching condition exists on the active problem list, flag as: "Patient is on [medication] but [condition] is not on the active problem list." ### Step 5: Check for Conditions Without Active Treatment For each active condition, check if there is at least one active medication or recent encounter addressing it. **Flag Type B -- Untreated Active Condition:** - Active condition with no medication from the expected drug class - No encounter in the last 12 months with the condition as a reason code - Exception: conditions that may not require pharmacotherapy (e.g., obesity managed with lifestyle, resolved fracture under monitoring) ### Step 6: Identify Resolved Conditions Still Listed as Active **Flag Type C -- Potentially Resolved Conditions:** - Condition has `clinicalStatus` = active but `abatementDateTime` is in the past - Condition is an acute diagnosis (e.g., pneumonia, UTI, fracture) with onset > 6 months ago and no recent encounter referencing it - Condition was treated with a medication that has been stopped Verify with lab data where applicable: ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&code=[relevant-LOINC]&_sort=-date&_count=1" ``` Examples: - "Diabetes" active but latest HbA1c (LOINC 4548-4) is consistently < 5.7% for 2+ years and no diabetes medications active - "Hypothyroidism" active but latest TSH (LOINC 3016-3) normal and no levothyroxine prescribed - "Iron deficiency anemia" active but latest ferritin (LOINC 2276-4) and hemoglobin (LOINC 718-7) both normal ### Step 7: Assess ICD-10 Coding Specificity For each active condition, check if the ICD-10 code can be made more specific: **Flag Type D -- Coding Specificity Opportunities:** | Current Code | Issue | Suggested Improvement | |-------------|-------|----------------------| | E11.9 (Type 2 DM without complications) | Patient has documented neuropathy or nephropathy | E11.40 (with neuropathy) or E11.22 (with CKD) | | I10 (Essential hypertension) | Adequate but check for hypertensive heart/kidney disease | I11.x, I12.x, I13.x if applicable | | E78.5 (Hyperlipidemia, unspecified) | Can specify type | E78.00 (pure hypercholesterolemia), E78.1 (hypertriglyceridemia) | | J45.20 (Mild intermittent asthma, uncomplicated) | Patient on daily controller | J45.30 (mild persistent) or higher | | M17.9 (Osteoarthritis of knee, unspecified) | Laterality missing | M17.11 (right), M17.12 (left) | | F32.9 (Major depressive disorder, unspecified) | Can specify episode/severity | F32.0 (mild), F32.1 (moderate), F32.2 (severe) | ### Step 8: Format Output ``` PROBLEM LIST REVIEW =================== Patient: [name] ([patient-id]) Reviewed: [timestamp] Active Conditions: [count] Inactive/Resolved: [count] Active Medications: [count] ACTIVE PROBLEM LIST ------------------- 1. [Condition] - SNOMED: [code] / ICD-10: [code] - Onset: [date] Treatment: [matching medication(s)] 2. ... FINDINGS -------- [A] MISSING DIAGNOSES (Medications imply undocumented conditions) 1. On Metformin 1000mg BID but Type 2 Diabetes not on problem list -> Recommend adding: E11.9 Type 2 diabetes mellitus without complications 2. ... [B] UNTREATED CONDITIONS 1. Essential hypertension (I10) - Active since 2020 - No antihypertensive medication found -> Verify: Is patient on lifestyle management only? If pharmacotherapy indicated, address. 2. ... [C] POTENTIALLY RESOLVED CONDITIONS 1. Acute bronchitis (J20.9) - Onset: 2025-03-15 - Still listed as active -> Recommend: Update clinicalStatus to "resolved" 2. ... [D] CODING SPECIFICITY OPPORTUNITIES 1. E11.9 (DM2 without complications) - Patient has documented diabetic neuropathy -> Recommend: E11.40 (Type 2 DM with diabetic neuropathy) 2. ... SUMMARY ------- - [N] conditions reviewed - [N] missing diagnoses identified - [N] conditions potentially untreated - [N] conditions potentially resolved - [N] coding improvements suggested ``` ## Examples ### Example 1: Routine Problem List Audit **User says:** "Review the problem list for patient 44321" **Actions:** 1. `fhir_search` Condition?patient=44321 -- returns 8 conditions (6 active, 2 resolved) 2. `fhir_search` MedicationRequest?patient=44321&status=active -- returns 7 active medications 3. `fhir_search` Encounter?patient=44321&date=ge2025-02-07&_sort=-date -- returns 4 encounters **Cross-reference findings:** - Metformin 1000mg and Glipizide 5mg on med list, "Type 2 Diabetes" IS on problem list. OK. - Lisinopril 20mg on med list, "Hypertension" IS on problem list. OK. - Omeprazole 20mg on med list, but NO GERD or peptic ulcer on problem list. FLAG A. - Sertraline 100mg on med list, but NO depression or anxiety on problem list. FLAG A. - "Acute sinusitis" (J01.90) onset 2025-01-10, still active, no recent encounter. FLAG C. - Diabetes coded as E11.9 but patient also has documented CKD Stage 3. FLAG D: suggest E11.22. **Result:** Formatted report with 2 missing diagnoses, 1 potentially resolved condition, 1 coding improvement. ### Example 2: Post-Discharge Problem List Reconciliation **User says:** "Audit the problem list for patient 77890 after their hospital stay" **Actions:** 1. `fhir_search` Condition?patient=77890 -- returns 12 conditions 2. `fhir_search` MedicationRequest?patient=77890&status=active -- returns 10 medications 3. `fhir_search` Encounter?patient=77890&date=ge2025-02-07&_sort=-date -- returns 6 encounters including inpatient stay **Findings:** - New medications from discharge (apixaban, metoprolol) without corresponding new diagnoses added (atrial fibrillation). FLAG A. - Hospital-acquired pneumonia on problem list from admission, patient discharged 3 weeks ago with completed antibiotic course. FLAG C. - "Heart failure" (I50.9, unspecified) could be I50.22 (chronic systolic, compensated) based on echo results. FLAG D. ## Troubleshooting ### Condition Resources Use Only ICD-10 Codes Without SNOMED - Cross-reference is still possible. Use the ICD-10 code directly for matching. - Note that some medication-condition mappings are more reliable with SNOMED codes. Use the display text as a fallback for matching. ### MedicationRequest Uses medicationReference Instead of medicationCodeableConcept - The medication details are in a separate Medication resource. Resolve the reference: ``` Tool: fhir_read resourceType: "Medication" id: "[medication-reference-id]" ``` - Extract the drug name from `Medication.code.coding`. ### Too Many Conditions Returned (Including Historical) - Filter client-side by `category` = "problem-list-item" to exclude encounter-only diagnoses. - Sort by `clinicalStatus` to prioritize active conditions. - If the list exceeds 50 items, paginate with `_count=50` and follow `Bundle.link` where `relation` = "next". ## Related Skills - `clinical-summary-generator` -- for full chart summary including problems in context - `allergy-adverse-reaction-summary` -- for allergy-specific review - `patient-demographics-summary` -- when problem list review reveals missing demographic data --- > Converted and distributed by [TomeVault](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.