# Langcare Langcare MCP Fhir Procedure Note Template > Procedure Note Template - Skill: `tomevault-io/langcare-langcare-mcp-fhir-procedure-note-template` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-procedure-note-template` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-procedure-note-template/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-procedure-note-template --- # Procedure Note Template ## Overview Generate pre-populated procedure documentation templates from FHIR data. Pull patient demographics, procedure indication from active conditions, relevant pre-procedure labs (coagulation studies, platelets, hemoglobin), allergy list, and current anticoagulant status. Include required elements: informed consent verification, time-out documentation, procedure details, specimen handling, complications, and post-procedure orders. Support common bedside procedures: central venous catheter, arterial line, intubation, lumbar puncture, paracentesis, thoracentesis, chest tube, foley catheter, and NG tube. ## FHIR Resources Used | Resource | Purpose | Key Fields | |----------|---------|------------| | Patient | Demographics for note header | name, birthDate, gender, identifier | | Condition | Procedure indication | code, clinicalStatus | | Observation | Pre-procedure labs (coags, CBC), vitals | code, value[x], effectiveDateTime | | AllergyIntolerance | Allergy check (esp. latex, iodine, lidocaine) | code, reaction, clinicalStatus | | MedicationRequest | Anticoagulant status, sedation orders | medicationCodeableConcept, status, dosageInstruction | | MedicationAdministration | Sedation medications given | medicationCodeableConcept, dosage, effectiveDateTime | | Consent | Informed consent status | status, scope, dateTime | | Procedure | Create procedure record | code, status, performedDateTime, outcome, complication | ## Instructions ### Step 1: Retrieve Patient Demographics ``` Tool: fhir_read resourceType: "Patient" id: "[patient-id]" ``` Extract: name, DOB, age, gender, MRN for procedure note header and patient identification band verification. ### Step 2: Identify Procedure Indication ``` Tool: fhir_search resourceType: "Condition" queryParams: "patient=[patient-id]&clinical-status=active" ``` Match the stated procedure to an active condition as the indication. Common mappings: - Central line: difficult IV access, need for vasopressors, TPN, prolonged IV antibiotics - Arterial line: hemodynamic instability, frequent ABG monitoring - Intubation: respiratory failure, airway protection - Lumbar puncture: meningitis workup, subarachnoid hemorrhage evaluation - Paracentesis: ascites (tense, diagnostic) - Thoracentesis: pleural effusion (diagnostic or therapeutic) - Chest tube: pneumothorax, hemothorax, empyema - Foley catheter: urinary retention, strict I&O monitoring, perioperative - NG tube: bowel obstruction, GI decompression, medication administration ### Step 3: Pull Pre-Procedure Labs ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&category=laboratory&code=http://loinc.org|5902-2,http://loinc.org|6301-6,http://loinc.org|777-3,http://loinc.org|718-7,http://loinc.org|3173-2&_sort=-date&_count=20" ``` Critical pre-procedure LOINC codes: - 5902-2: PT (Prothrombin time) - 6301-6: INR - 3173-2: aPTT (Activated partial thromboplastin time) - 777-3: Platelet count - 718-7: Hemoglobin - 4544-3: Hematocrit Flag if: - INR > 1.5 (relative contraindication for most invasive procedures) - Platelets < 50,000 (increased bleeding risk) - Platelets < 20,000 (contraindication without transfusion) - aPTT > 1.5x control - Hemoglobin < 7 (consider transfusion before elective procedure) - Labs > 24 hours old (recommend recheck) ### Step 4: Check Allergies ``` Tool: fhir_search resourceType: "AllergyIntolerance" queryParams: "patient=[patient-id]&clinical-status=active" ``` Flag procedure-relevant allergies: - **Latex**: Use non-latex gloves, equipment - **Iodine/Betadine**: Use chlorhexidine for skin prep - **Chlorhexidine**: Use betadine for skin prep - **Lidocaine/local anesthetics**: Use alternative anesthetic, allergy consult - **Adhesive/tape**: Use alternative securement - **Heparin** (HIT): Avoid heparin-coated catheters and flushes ### Step 5: Check Anticoagulant Status ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active&category=http://terminology.hl7.org/CodeSystem/medicationrequest-category|inpatient" ``` Check active medications for anticoagulants and antiplatelets: - Heparin drip: Check if held, last aPTT value - Enoxaparin: Timing of last dose (hold 12h for prophylactic, 24h for therapeutic) - Warfarin: Current INR - DOACs (apixaban, rivarelbán, edoxaban): Timing of last dose (hold 24-48h) - Clopidogrel, prasugrel, ticagrelor: Document if held - Aspirin: Generally continued for most bedside procedures ### Step 6: Check Consent Status ``` Tool: fhir_search resourceType: "Consent" queryParams: "patient=[patient-id]&status=active&scope=treatment" ``` If no procedure-specific consent found, flag: "INFORMED CONSENT: NOT DOCUMENTED -- obtain before proceeding." ### Step 7: Pull Pre-Procedure Vitals ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&category=vital-signs&_sort=-date&_count=10" ``` Document baseline vitals before procedure. ### Step 8: Assemble Procedure Note Template ``` PROCEDURE NOTE =============== Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender] Date/Time: [procedure datetime] Procedure: [procedure name] Operator: [Flag: "Enter operator name and credentials"] Supervising Physician: [if applicable] Service: [service] INDICATION ---------- [Condition from Step 2 with ICD-10 code] INFORMED CONSENT ---------------- [Consent status from Step 6] Risks, benefits, and alternatives discussed with: [patient / surrogate] Consent signed: [date/time or "REQUIRED"] ALLERGIES --------- [List with procedure-relevant flags] PRE-PROCEDURE VERIFICATION (TIME-OUT) -------------------------------------- - [ ] Correct patient (two-identifier verification) - [ ] Correct procedure confirmed - [ ] Correct site/laterality marked (if applicable) - [ ] Informed consent obtained - [ ] Relevant labs reviewed: PT/INR: [value] ([date]) [FLAG if abnormal] Platelets: [value] ([date]) [FLAG if abnormal] Hemoglobin: [value] ([date]) [FLAG if abnormal] aPTT: [value] ([date]) [FLAG if abnormal] - [ ] Anticoagulant status: [status from Step 5] - [ ] Allergies reviewed: [summary] - [ ] Equipment and supplies verified PRE-PROCEDURE VITALS --------------------- HR: [hr] | BP: [sys]/[dia] | RR: [rr] | SpO2: [spo2]% on [O2] SEDATION / ANESTHESIA ---------------------- [Flag: "Complete if conscious sedation used"] Sedation type: [none / local only / moderate sedation / deep sedation] Medications administered: - [Drug] [dose] [route] [time] [Flag: "Enter"] - [Drug] [dose] [route] [time] [Flag: "Enter"] Pre-sedation assessment: ASA class [I-V], Mallampati [I-IV], NPO status [hours] Monitoring: Continuous pulse oximetry, cardiac monitor, ETCO2 (if applicable) PROCEDURE DETAILS ----------------- [Flag: "Operator to complete procedure details"] Position: [supine / lateral decubitus / sitting / Trendelenburg] Skin prep: [chlorhexidine / betadine] [Note allergy-based selection] Draping: Sterile draping applied Anesthesia: [lidocaine X% / bupivacaine X%] [volume] mL infiltrated to [site] Technique: [Description of procedure steps] Site: [anatomical location, laterality] [Procedure-specific fields -- see references/procedure-documentation.md] SPECIMENS --------- [If applicable] Type: [fluid / tissue / culture] Sent to: [lab / microbiology / cytology / pathology] Tests ordered: [cell count, culture, protein, glucose, LDH, cytology, etc.] Labeled: [Yes -- two-identifier verification] ESTIMATED BLOOD LOSS -------------------- [volume] mL COMPLICATIONS ------------- [None / describe] [Procedure-specific complication checklist -- see references/procedure-safety.md] POST-PROCEDURE -------------- Patient tolerated procedure: [well / with complications] Post-procedure vitals: HR [hr] | BP [sys]/[dia] | SpO2 [spo2]% Post-procedure imaging ordered: [CXR for central line/chest tube / none] Post-procedure orders: - [Site check q[interval]] - [Dressing change instructions] - [Activity restrictions] - [Lab follow-up] DISPOSITION ----------- Patient returned to: [floor / ICU / recovery] Attending notified: [Yes/No] ``` ### Step 9: Create Procedure Resource in FHIR ``` Tool: fhir_create resourceType: "Procedure" resource: { "resourceType": "Procedure", "status": "completed", "code": { "coding": [{ "system": "http://www.ama-assn.org/go/cpt", "code": "[CPT-code]", "display": "[procedure-name]" }] }, "subject": {"reference": "Patient/[patient-id]"}, "encounter": {"reference": "Encounter/[encounter-id]"}, "performedDateTime": "[procedure-datetime]", "performer": [{ "actor": {"reference": "Practitioner/[practitioner-id]"} }], "reasonReference": [{"reference": "Condition/[indication-condition-id]"}], "outcome": { "coding": [{ "system": "http://snomed.info/sct", "code": "385669000", "display": "Successful" }] }, "note": [{"text": "[brief procedure summary]"}] } ``` Common CPT codes: - 36556: Central venous catheter insertion (non-tunneled) - 36620: Arterial line insertion - 31500: Intubation, endotracheal - 62270: Lumbar puncture - 49083: Paracentesis - 32555: Thoracentesis - 32551: Chest tube insertion - 51702: Foley catheter insertion - 43752: NG tube insertion ## Examples ### Example 1: Central Line Placement **User says**: "Procedure note for central line placement on patient 11111." **Actions**: 1. `fhir_read` Patient/11111. Returns: James Torres, DOB 1955-06-30, Male, MRN-11111. 2. `fhir_search` Condition active. Returns: Septic shock (R65.21), pneumonia (J18.9), T2DM, CKD4. 3. `fhir_search` Observation labs (coags, CBC). Returns: INR 1.2, platelets 188k, Hgb 9.8, aPTT 28. 4. `fhir_search` AllergyIntolerance. Returns: Latex allergy (urticaria). Flag: USE NON-LATEX EQUIPMENT. 5. `fhir_search` MedicationRequest anticoagulants. Returns: Heparin drip active -- held 2 hours ago, aPTT at hold was 55. 6. `fhir_search` Observation vitals. Returns: HR 105, BP 88/52 on norepinephrine, SpO2 96% on 4L NC. **Result**: ``` PROCEDURE NOTE =============== Patient: James Torres | MRN: MRN-11111 | DOB: 1955-06-30 (Age: 68) | Sex: Male Procedure: Central venous catheter insertion (non-tunneled) INDICATION: Septic shock requiring vasopressor administration (R65.21) ALLERGIES ** LATEX ALLERGY (urticaria) -- USE NON-LATEX GLOVES AND EQUIPMENT ** PRE-PROCEDURE VERIFICATION - Labs: INR 1.2 [OK] | Platelets 188k [OK] | Hgb 9.8 [OK] | aPTT 28 [OK] - Anticoagulant: Heparin drip HELD 2h ago, aPTT at hold: 55 - Consent: [VERIFY] PRE-PROCEDURE VITALS HR: 105 | BP: 88/52 (on norepinephrine) | SpO2: 96% on 4L NC [Procedure details: operator to complete -- site, technique, number of attempts, catheter type/size, line placement confirmation method, post-procedure CXR ordered] ``` ### Example 2: Lumbar Puncture **User says**: "Generate LP procedure note template for patient pt-222, meningitis workup." **Actions**: 1. `fhir_read` Patient/pt-222. Returns: Emily Park, DOB 1990-03-22, Female. 2. `fhir_search` Condition. Returns: Fever of unknown origin (R50.9), headache (R51.9), nuchal rigidity (R29.1). 3. `fhir_search` Observation labs. Returns: INR 1.0, platelets 245k, Hgb 12.8, WBC 18.5. 4. `fhir_search` AllergyIntolerance. Returns: NKDA. 5. `fhir_search` MedicationRequest. Returns: No anticoagulants active. 6. `fhir_search` Observation vitals. Returns: T 39.2C, HR 110, BP 128/78, SpO2 99% RA. **Result**: Pre-populated LP template with indication (meningitis workup), normal coags confirmed, no allergy concerns, specimen handling section pre-filled (tube 1: cell count/diff, tube 2: glucose/protein, tube 3: Gram stain/culture, tube 4: hold for additional studies), opening pressure documentation field, post-LP instructions (flat 1-2 hours, monitor for headache). ## Troubleshooting ### Pre-procedure labs are older than 24 hours - Flag prominently: "Labs dated [date] -- [X] hours old. Consider recheck before procedure if clinically indicated." - For INR and platelets, 24-48 hours is generally acceptable if no interval events (bleeding, transfusion, new anticoagulation). - For hemoglobin in actively bleeding patients, recommend point-of-care testing. ### Consent resource not found in FHIR - Consent resources are not universally implemented in FHIR servers. Many systems store consent in paper or scanned documents. - Search DocumentReference for scanned consent: `fhir_search` DocumentReference with `patient=[id]&type=http://loinc.org|59284-0` (LOINC 59284-0 = Consent document). - If not found, prominently flag: "INFORMED CONSENT STATUS: UNABLE TO VERIFY IN ELECTRONIC RECORD -- confirm paper consent before proceeding." ### Procedure-specific CPT code not in standard list - Use SNOMED CT coding as an alternative: `system: "http://snomed.info/sct"`. - Common SNOMED codes: 233573008 (central line), 52765003 (intubation), 277762005 (lumbar puncture), 86088003 (paracentesis), 91602002 (thoracentesis). - If no standard code matches, use `code.text` with the procedure name as free text. ## Related Skills - `soap-note-generator` - For documenting the encounter containing the procedure - `progress-note-writer` - For post-procedure daily documentation - `lab-result-interpreter` - For interpreting pre-procedure lab values - `preoperative-lab-checklist` - For verifying all required pre-procedure labs are current --- > Converted and distributed by [TomeVault](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.