clinical-documentation

clinical-documentation is a skill for Claude Code from aks-builds/healthcareskills. It costs 185 tokens per session (3,244 once invoked), scanned A, original, MIT.

Guidance for designing clinical documentation workflows, templates, or systems that handle medical notes and structured health-record data.

In plain words
What is it for?
Use it for workflows involving progress notes, histories and physicals, SOAP notes, discharge summaries, operative notes, clinical note ingestion, or documentation produced by scribes.
Why use it?
It helps software match how clinicians write notes and addresses privacy, consent, clinical settings, and sending documentation back to an electronic health record.

Skill for Claude Code

Written for Claude Code: shipped in a Claude Code plugin.

Part of the healthcare-skills plugin — 41 skills shipped together , and of healthcare-skills

Good fit Use it for workflows involving progress notes, histories and physicals, SOAP notes, discharge summaries, operative notes, clinical note ingestion, or documentation produced by scribes.

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Install with agentmods
npx agentmods add skills/aks-builds/healthcareskills/clinical-documentation
Install

Getting it into your agent

One page per mod, every tool's command on it. A separate URL per tool would split the same page into five that compete with each other.

Any agent
npx skills add aks-builds/healthcareskills --skill clinical-documentation
Clone the repo
git clone --depth 1 https://github.com/aks-builds/healthcareskills

Made for: Claude Code.

Or install healthcare-skills, the plugin that ships this one along with the rest of its 41 skills.

Wrote this? Show the measurements

A badge with what this costs and how it scanned, read live from this page, so it follows the numbers instead of freezing them. Markdown for a README, HTML for a documentation site or a project page.

agentmods badge for clinical-documentation

README.md
[![agentmods](https://agentmods.dev/badge/skills/aks-builds/healthcareskills/clinical-documentation/github.svg)](https://agentmods.dev/skills/aks-builds/healthcareskills/clinical-documentation)
Your own site
<a href="https://agentmods.dev/skills/aks-builds/healthcareskills/clinical-documentation"><img src="https://agentmods.dev/badge/skills/aks-builds/healthcareskills/clinical-documentation/github.svg" alt="Measured on agentmods" height="20"></a>

Or the 80×15 button, for a site that already has a row of RSS and ATOM ones. Only the verdict fits; the numbers stay here.

agentmods 80×15 button for clinical-documentation

Your own site · 80×15
<a href="https://agentmods.dev/skills/aks-builds/healthcareskills/clinical-documentation"><img src="https://agentmods.dev/badge/skills/aks-builds/healthcareskills/clinical-documentation.svg" alt="Reviewed on agentmods" width="80" height="20"></a>
Per session 185 Skills are progressive disclosure: only the name and description are preloaded; the body loads when the skill is used.
When invoked 3,244 The whole file, excluding the scripts and references it only reads on demand.
Security scan A 0 findings. A grade says what 26 rules found in the file — not that it is safe.
Origin original No closer match found in the catalogue.
Token cost

What it costs to keep this loaded

Counted locally with the o200k_base tokenizer, which is exact for GPT models; Claude uses its own tokenizer and its counts differ. Treat this as one consistent yardstick across the catalogue rather than a bill. Prices are per million input tokens.

ModelPer sessionOnce invoked
Fable 5.1 $0.00185 $0.03244
Opus 5 $0.00093 $0.01622
Sonnet 5 $0.00037 $0.00649
Haiku 4.5 $0.00018 $0.00324

Measured 11d ago against content hash f93169086d05, method: parsed. Prices are Anthropic first-party input rates as of 2026-09-11, from the pricing page.

Security

Grade A, and why

clinical-documentation scanned grade A with 0 findings against 26 rules in 11 categories — prompt injection, anti-refusal, data exfiltration, privilege escalation, supply chain, agent snooping, system-prompt leakage, SSRF and excessive agency — measured 11d ago.

A static scan of the body, not an audit. Every finding is printed with the line that produced it so you can judge whether it matters here. A mod is markdown that instructs an agent; that is exactly why what it instructs is worth reading.

Nothing flagged

None of the 26 patterns this scan looks for appear in this file: no shell pipes, no recursive deletes, no credential paths, no hidden text, no instruction-override or anti-refusal phrasing, no agent-config snooping. That is not a guarantee, it is the absence of the things that are checkable.

skills/clinical-documentation/SKILL.md · 259 lines

How it starts

The opening of the file, as written. The whole thing — 259 lines — stays where its author put it; the contents beside it link to each section on GitHub.

Clinical Documentation

You are an expert in clinical documentation — how clinicians actually write notes, what structured data those notes generate, and how to capture, parse, and write back documentation in modern EHRs. Your goal is to help engineers build documentation tooling that is faithful to clinical workflow, generates the right structured data, and respects privacy and consent.

Initial Assessment

Read .agents/healthcare-context.md first (fall back to .claude/healthcare-context.md). The context file tells you which EHRs to target, which clinical settings (which drives note types), and whether you are a covered entity, a Business Associate, or a vendor building an ambient scribe.

If the context file does not exist, ask:

  1. What documentation workflow — inpatient, ambulatory, ED, peri-op, behavioral health?
  2. Are you ingesting notes (NLP / abstraction) or producing them (templates, scribes)?
  3. Which EHR(s)? How will the note get back into the chart?
  4. Is ambient capture (audio) involved? If so, what is the consent flow?
  5. Who is the user — physician, advanced practice provider, scribe, medical coder?

Note Types

Type When Typical sections LOINC document type
History & Physical (H&P) At admission or new patient CC, HPI, ROS, PMH, FH, SH, exam, A&P Verify against current LOINC release
Progress note Daily, during encounter Subjective, objective, assessment, plan Verify against current LOINC release
Discharge summary At discharge Course, diagnoses, meds at discharge, follow-up, disposition Verify against current LOINC release
Operative note Post-procedure Pre-op dx, post-op dx, procedure, findings, EBL, complications Verify against current LOINC release
Consult note Specialist consult Reason for consult, findings, recommendations Verify against current LOINC release
Procedure note Bedside / minor procedure Indication, technique, findings, complications Verify against current LOINC release
Telephone / message Async patient communication Message, action taken Verify against current LOINC release

Read the full file on GitHub · 259 lines

Files

What ships with it

3 files beside SKILL.md in the same directory: the scripts, references and assets a skill reads on demand. Not counted in the per-session cost; read them before you install if any of them is executable.

Changes

What this file has done since we first saw it

Hashed on every crawl. A supply-chain change to an agent config is a question of when, not whether, so the history is kept rather than the latest state alone.

  1. 11d ago First seen · 259 lines · 185 tokens per session scan A f93169086d05

Subscribe to this mod's changes

clinical-documentation is a skill published in the GitHub repository aks-builds/healthcareskills (1 stars, last pushed 2d ago), licensed MIT. It adds 185 tokens to every session and 3,244 once invoked, about $0.0009 per session on Opus 5. A static security scan graded it A with 0 findings. No closer match exists in the catalogue, so it is treated as the original; first seen 2026-08-31.

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