# Langcare Langcare MCP Fhir Progress Note Writer > Progress Note Writer - Skill: `tomevault-io/langcare-langcare-mcp-fhir-progress-note-writer` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-progress-note-writer` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-progress-note-writer/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-progress-note-writer --- # Progress Note Writer ## Overview Generate structured daily inpatient progress notes by pulling 24-hour data windows from FHIR resources. Assemble vitals trends, intake and output, laboratory results, imaging results, medication changes, and overnight events into a problem-oriented format. Include standing order status for DVT prophylaxis, GI prophylaxis, diet, activity level, and code status. Flag critical values and significant changes from prior day. ## FHIR Resources Used | Resource | Purpose | Key Fields | |----------|---------|------------| | Encounter | Admission context, hospital day calculation | period.start, status, class | | Patient | Demographics for note header | name, birthDate, gender, identifier | | Observation | Vitals, labs, I&O, Glasgow score | code, value[x], effectiveDateTime, category | | MedicationRequest | Active medications, new orders, changes | medicationCodeableConcept, status, authoredOn, dosageInstruction | | MedicationAdministration | Medications actually given in 24h | medicationCodeableConcept, effectiveDateTime, dosage | | DiagnosticReport | Imaging, pathology results | code, conclusion, effectiveDateTime, result | | Condition | Active problem list for assessment | code, clinicalStatus | | Procedure | Procedures in last 24h | code, performedDateTime, status | | CarePlan | Diet, activity, DVT/GI prophylaxis | category, activity, status | ## Instructions ### Step 1: Retrieve Encounter and Calculate Hospital Day ``` Tool: fhir_read resourceType: "Encounter" id: "[encounter-id]" ``` Calculate hospital day: `(today - period.start) + 1`. Extract admitting diagnosis from `reasonCode`. If encounter ID unknown: ``` Tool: fhir_search resourceType: "Encounter" queryParams: "patient=[patient-id]&class=IMP&status=in-progress&_sort=-date&_count=1" ``` ### Step 2: Retrieve Patient Demographics ``` Tool: fhir_read resourceType: "Patient" id: "[patient-id]" ``` ### Step 3: Pull 24-Hour Vital Signs Trends Define the 24-hour window: `[today 00:00]` to `[now]`, or `[yesterday same-time]` to `[now]`. ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&category=vital-signs&date=ge[24h-ago]&_sort=date&_count=100" ``` Present as trends: - **Temperature**: Tmax, Tcurrent (flag if Tmax >= 38.0 C / 100.4 F) - **Heart rate**: Range (low-high), current - **Blood pressure**: Range, current (flag if MAP < 65 or SBP > 180) - **Respiratory rate**: Range, current - **SpO2**: Range, current, oxygen delivery method if available - **Pain score** (LOINC 72514-3): Most recent ### Step 4: Pull Intake and Output ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&code=http://loinc.org|9187-6&date=ge[24h-ago]" ``` LOINC codes for I&O: - 9187-6: Fluid intake 24h - 9192-6: Fluid output 24h - Also search: `code=http://loinc.org|9192-6` Calculate net fluid balance. Flag if net positive > 1L or net negative > 2L. If I&O Observations not available, note: "I&O data not captured in structured FHIR observations -- obtain from nursing flowsheet." ### Step 5: Pull Laboratory Results (24h) ``` Tool: fhir_search resourceType: "Observation" queryParams: "patient=[patient-id]&category=laboratory&date=ge[24h-ago]&_sort=-date&_count=50" ``` Group by panel. For each result: - Compare to prior value if available (trend direction) - Flag abnormal values with reference range - Highlight critical values (e.g., K < 3.0 or > 6.0, Na < 125 or > 155, Hgb < 7, platelets < 50k, lactate > 4) ### Step 6: Pull Imaging and Diagnostic Reports (24h) ``` Tool: fhir_search resourceType: "DiagnosticReport" queryParams: "patient=[patient-id]&date=ge[24h-ago]&_sort=-date" ``` Extract `conclusion` or `presentedForm` text. If results reference Observation resources in `result`, follow references with `fhir_read`. ### Step 7: Pull Active Medications and 24h Changes **7a: Current active orders** ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active&_count=100" ``` **7b: Medications administered in 24h** ``` Tool: fhir_search resourceType: "MedicationAdministration" queryParams: "patient=[patient-id]&effective-time=ge[24h-ago]&_count=100" ``` Identify: - New medications started in 24h (`authoredOn` within window) - Dose changes - Discontinued medications (`status=stopped` with `authoredOn` in window) - PRN medications administered with frequency ### Step 8: Pull Procedures Performed in 24h ``` Tool: fhir_search resourceType: "Procedure" queryParams: "patient=[patient-id]&date=ge[24h-ago]" ``` ### Step 9: Pull Active Problem List ``` Tool: fhir_search resourceType: "Condition" queryParams: "patient=[patient-id]&clinical-status=active" ``` ### Step 10: Check Standing Orders and Prophylaxis Search for prophylaxis orders: **DVT prophylaxis:** ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active&code=http://www.nlm.nih.gov/research/umls/rxnorm|67108" ``` RxNorm 67108 = enoxaparin. Also check: 11289 (heparin). **GI prophylaxis:** ``` Tool: fhir_search resourceType: "MedicationRequest" queryParams: "patient=[patient-id]&status=active&code=http://www.nlm.nih.gov/research/umls/rxnorm|40790" ``` RxNorm 40790 = pantoprazole. Also check: 29046 (famotidine). If prophylaxis not found, flag as gap. **Diet and activity**: Check CarePlan resources: ``` Tool: fhir_search resourceType: "CarePlan" queryParams: "patient=[patient-id]&status=active&category=http://hl7.org/fhir/us/core/CodeSystem/careplan-category|assess-plan" ``` ### Step 11: Assemble Progress Note ``` DAILY PROGRESS NOTE ==================== Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) Date: [today] | Hospital Day #[n] | Admitting Dx: [diagnosis] Service: [service] | Attending: [attending] OVERNIGHT EVENTS ---------------- [Flag: "Obtain from nursing/overnight team if not in structured data"] [Include any 24h procedures, code/rapid response events, new consults] SUBJECTIVE ---------- [Flag: "Obtain from patient interview"] Pain: [score from LOINC 72514-3 if available] 24-HOUR VITALS -------------- Tmax: [max temp] | Tcurrent: [current] HR: [range] ([current]) | BP: [range] ([current]) RR: [range] ([current]) | SpO2: [range]% on [O2 device] INTAKE & OUTPUT (24h) --------------------- Intake: [total] mL | Output: [total] mL | Net: [+/-] mL [Flag if significantly positive or negative] LABORATORIES ------------ [Panel groupings with trend arrows] BMP: Na [val][trend] | K [val][trend] | Cr [val][trend] | BUN [val][trend] | Gluc [val][trend] CBC: WBC [val][trend] | Hgb [val][trend] | Plt [val][trend] [Additional labs] [CRITICAL VALUES flagged] IMAGING / STUDIES ----------------- [From DiagnosticReport conclusions] MEDICATIONS ----------- Active Medications: [count] New (24h): [list] Changed (24h): [list] Discontinued (24h): [list] PRN Given: [list with frequency] ASSESSMENT & PLAN (by problem) ------------------------------ 1. [Primary problem] - [ICD-10] - Status: [improving/stable/worsening based on objective data] - Plan: [Flag: "Clinician input required"] 2. [Secondary problem] - [ICD-10] - Status: [assessment] - Plan: [Flag: "Clinician input required"] STANDING ORDERS --------------- DVT Prophylaxis: [medication or "NOT ORDERED - ACTION REQUIRED"] GI Prophylaxis: [medication or "Not indicated" or "NOT ORDERED - verify"] Diet: [from CarePlan or "Verify"] Activity: [from CarePlan or "Verify"] Code Status: [from Consent or "Verify"] DISPOSITION ----------- Estimated discharge: [if available from Encounter.hospitalization] Barriers to discharge: [Flag: "Clinician input"] ``` ## Examples ### Example 1: Medical Floor Progress Note **User says**: "Write today's progress note for patient 67890, admitted for pneumonia." **Actions**: 1. `fhir_search` Encounter for patient 67890, class=IMP, status=in-progress. Returns ENC-MED-300, admitted 2024-03-13, reasonCode="Community-acquired pneumonia". Today is 2024-03-15 = Hospital Day #3. 2. `fhir_read` Patient/67890. Returns: Alice Chen, DOB 1965-07-22, Female. 3. `fhir_search` Observation vital-signs 24h. Returns: Tmax 38.2C (overnight), Tcurrent 37.1C, HR 78-92 (current 82), BP 118-132/68-78, RR 16-20, SpO2 94-97% on 2L NC. 4. `fhir_search` Observation I&O. Returns: Intake 2400mL, Output 1800mL, Net +600mL. 5. `fhir_search` Observation laboratory 24h. Returns: WBC 11.2 (down from 15.8), procalcitonin 0.8 (down from 2.1), BMP normal. 6. `fhir_search` DiagnosticReport 24h. Returns: CXR - "Right lower lobe consolidation, improved from prior." 7. `fhir_search` MedicationRequest active. Returns: ceftriaxone 1g IV daily (day 3), azithromycin 500mg PO daily (day 3), enoxaparin 40mg SQ daily, pantoprazole 40mg IV daily, acetaminophen 650mg PO q6h PRN. 8. `fhir_search` Condition active. Returns: CAP (J18.9), HTN (I10), T2DM (E11.9). **Result**: ``` DAILY PROGRESS NOTE ==================== Patient: Alice Chen | MRN: MRN-67890 | DOB: 1965-07-22 (Age: 58) Date: 2024-03-15 | Hospital Day #3 | Admitting Dx: Community-acquired pneumonia 24-HOUR VITALS Tmax: 38.2C (overnight) -> Tcurrent: 37.1C [IMPROVING - fever curve trending down] HR: 78-92 (82) | BP: 118-132/68-78 | RR: 16-20 | SpO2: 94-97% on 2L NC I&O: Intake 2400mL | Output 1800mL | Net +600mL LABORATORIES WBC: 11.2 [DOWN from 15.8 - improving] Procalcitonin: 0.8 [DOWN from 2.1 - improving] BMP: Within normal limits IMAGING CXR (today): RLL consolidation, improved from prior ASSESSMENT & PLAN (by problem) 1. Community-acquired pneumonia (J18.9) - IMPROVING - Fever curve trending down, WBC and procalcitonin improving, CXR improved - Antibiotics: Ceftriaxone + Azithromycin day 3 of planned 5-day course - Continue 2L NC, wean O2 as tolerated 2. Hypertension (I10) - STABLE - BP within range on home medications 3. Type 2 diabetes (E11.9) - STABLE - Monitor fingerstick glucose STANDING ORDERS DVT Prophylaxis: Enoxaparin 40mg SQ daily [ACTIVE] GI Prophylaxis: Pantoprazole 40mg IV daily [ACTIVE] Diet: Verify Activity: Verify Code Status: Verify ``` ### Example 2: Post-Surgical Progress Note **User says**: "Progress note for patient pt-444, POD 1 from appendectomy." **Actions**: 1. `fhir_search` Encounter for pt-444, IMP, in-progress. Returns ENC-SURG-88, admitted 2024-03-14. 2. `fhir_read` Patient/pt-444. Returns: David Kim, DOB 2000-01-15, Male. 3. `fhir_search` Procedure 24h. Returns: Laparoscopic appendectomy, completed 2024-03-14. 4. `fhir_search` Observation vital-signs 24h. Returns: Tmax 37.8C, current normal, HR 70-85, BP normal, SpO2 99% RA. 5. `fhir_search` Observation laboratory 24h. Returns: WBC 9.8 (down from 18.2 pre-op), BMP normal. 6. `fhir_search` MedicationRequest active + MedicationAdministration 24h. Returns: ketorolac 15mg IV q6h, ondansetron 4mg IV q8h PRN (given x1), enoxaparin 40mg SQ daily, cefazolin 2g IV (single dose, perioperative). **Result**: Progress note with POD 1 framing, surgical site assessment flagged for clinician input, diet advancement plan, ambulation status, drain output if applicable, discharge criteria checklist. ## Troubleshooting ### MedicationAdministration not available on the FHIR server - This resource is optional in many FHIR implementations. Rely on MedicationRequest with `status=active` for the medication list. - Note in the progress note that administered medication data could not be verified. PRN usage will need to be obtained from nursing documentation. - Check if the encounter-level medication list is available through a different resource type. ### I&O data not captured in FHIR Observations - Intake/output is frequently not stored as discrete FHIR Observations. It may exist only in nursing flowsheets within the EHR. - Flag as: "I&O: Not available in structured FHIR data -- obtain from nursing flowsheet." - Do not fabricate I&O values. The note should explicitly state data is unavailable. ### DiagnosticReport returns references but no conclusion text - Follow `DiagnosticReport.result` references to individual Observation resources using `fhir_read`. - Check `DiagnosticReport.presentedForm` for full text attachments. - If neither is available, note: "[Study type] performed [date] -- result pending or not available in structured data." ## Related Skills - `history-and-physical-generator` - For the initial admission documentation - `soap-note-generator` - For outpatient encounter documentation - `discharge-summary-writer` - For discharge documentation when the patient is ready - `critical-value-alert-generator` - For flagging critical lab values found during note assembly --- > Converted and distributed by [TomeVault](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.