skills.rest
langcare
langcareOFFICIAL
Explore all skills by this author →
WebsiteGitHub

care-gap-identifier

A HIPAA-compliant clinical decision support system that tracks patient health records, flags missing vaccinations and screenings, generates customizable reports and reminders for clinicians and patients, and integrates seamlessly with EHRs to improve preventive care and reduce costs.

53|12|Updated Jan 26, 2026
Search Tags:#screening#fhir#clinical-decision-support#preventive-care#uspstf#care-gap
One-click install
npx skills add https://github.com/langcare/langcare-mcp-fhir --skill care-gap-identifier
Or copy as Structured Prompt for Agent▼
Please help me install this Agent Skill.
Skill: care-gap-identifier
Source: https://github.com/langcare/langcare-mcp-fhir/tree/main/skills/core/care-coordination/care-gap-identifier
Command: npx skills add https://github.com/langcare/langcare-mcp-fhir --skill care-gap-identifier

SYSTEM DOCUMENTATION & REQUIREMENTS

💡 This Skill includes references (resource) components.

What problem does it solve?

This skill helps clinicians identify preventive care gaps for patients by applying USPSTF grades A and B to existing data from FHIR resources, surfacing overdue and upcoming screenings.

Core Features & Use Cases

  • Aggregates patient demographics, risk factors, and prior screenings from FHIR (Patient, Observation, Procedure, Immunization, DiagnosticReport, MedicationStatement, Condition, FamilyMemberHistory) to determine gaps.
  • Generates patient-friendly care-gap summaries and prioritized action lists to support clinical decision-making and patient counseling.
  • Use Case: A clinician asks, "What preventive care is due for this patient?" The skill outputs overdue items, upcoming items within 6 months, and a patient-friendly summary.

Quick Start

Query patient care gaps by providing a patient ID to generate overdue and upcoming preventive services per USPSTF guidelines.

Frequently Asked Questions about care-gap-identifier

High-intent search queries and answers about installing and using this skill.

FAQPage Schema
How do I identify preventive care gaps using FHIR resources?▼

Preventive care gaps are identified by aggregating patient demographics, risk factors, and prior screenings from FHIR resources like Observation and Procedure. The skill applies USPSTF A and B recommendations to output structured summaries of overdue and upcoming services.

What preventive screenings are due for adult patients based on USPSTF guidelines?▼

Due preventive screenings for adult patients are determined by cross-referencing FHIR data against USPSTF A and B recommendations. The skill generates prioritized action lists and patient-friendly summaries for clinical decision-making and patient counseling.

Can I use patient FHIR data to find overdue clinical preventive services?▼

Yes, you can use patient FHIR data to find overdue clinical preventive services. By analyzing Patient, Immunization, and FamilyMemberHistory resources, the skill surfaces overdue screenings and items due within the next six months.

Does this care gap identifier support primary care chart reviews?▼

This care gap identifier supports primary care workflows and chart reviews by evaluating FHIR resources against USPSTF guidelines. It outputs patient-friendly gap summaries to facilitate patient counseling during clinical visits.

How do I generate a patient-friendly care gap summary from FHIR?▼

To generate a patient-friendly care gap summary from FHIR, provide a patient ID to query their records. The skill analyzes clinical data and outputs structured summaries detailing overdue and upcoming preventive services.

What FHIR resources are needed to check for preventive care gaps?▼

Checking for preventive care gaps requires FHIR resources including Patient, Observation, Procedure, Immunization, DiagnosticReport, FamilyMemberHistory, and Condition. These resources provide the demographics and clinical history needed for USPSTF analysis.

Related Skills

Explore More Education & Research Skills→
langcarelangcare
53

clinical-summary-generator

Generate CCD-style clinical summaries from multiple FHIR resources.

Official
Advanced
bandofaibandofai
3

Dunning Management Skill

Automate multi-tier dunning workflows for overdue payments.

Community
Intermediate
Victory-HugoVictory-Hugo
1

clinical-reports

Generate CARE-guideline-compliant clinical reports from standardized templates and references.

Community
Advanced
writerwriter
6

care-gap-identification

Identify missing or overdue care steps against HEDIS, STAR, and USPSTF measures.

Official
Advanced