What is care-gap-identifier?

A clinical screening helper that checks a patient’s records against preventive-care recommendations from the U.S. Preventive Services Task Force (USPSTF). It uses information such as age, sex, risk factors, past tests, and vaccinations.

Use it to review wellness needs, identify missing preventive care, and produce a prioritized list of due items with patient-friendly explanations.

It helps find screenings and vaccinations that are overdue or coming due without checking each record and recommendation by hand.

care-gap-identifier — Skill for Claude Code and Codex by langcare

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 langcare/langcare-mcp-fhir --skill care-gap-identifier

Clone the repo

git clone --depth 1 https://github.com/langcare/langcare-mcp-fhir

Made for: Claude Code, Codex.

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.

README.md

[![agentmods](https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/care-gap-identifier/github.svg)](https://agentmods.dev/skills/langcare/langcare-mcp-fhir/care-gap-identifier)

Your own site

<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/care-gap-identifier"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/care-gap-identifier/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.

Your own site · 80×15

<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/care-gap-identifier"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/care-gap-identifier.svg" alt="Reviewed on agentmods" width="80" height="20"></a>

Per session 106 Skills are progressive disclosure: only the name and description are preloaded; the body loads when the skill is used.

When invoked 4,260 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.

Model	Per session	Once invoked
Fable 5.1	$0.00106	$0.04260
Opus 5.5	$0.00042	$0.01704
Sonnet 5.5	$0.00021	$0.00852
Haiku 4.5	$0.00011	$0.00426

Measured 2mo ago against content hash ad439becd086, method: parsed. Prices are Anthropic first-party input rates as of 2026-10-07, from the pricing page.

Security

Grade A, and why

care-gap-identifier 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 2mo 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/core/care-coordination/care-gap-identifier/SKILL.md · 390 lines

How it starts

The opening of the file, as written. The whole thing — 390 lines — stays where its author put it; the contents beside it link to each section on GitHub.

Care Gap Identifier

Overview

Screen a patient for preventive care gaps based on USPSTF grade A and B recommendations. Query FHIR resources for prior screenings, immunizations, and relevant observations. Compare against age, sex, and risk-factor-adjusted intervals. Generate a prioritized list of overdue and upcoming preventive care items with patient-friendly descriptions.

FHIR Resources Used

Resource	Purpose	Key Fields
Patient	Demographics (age, sex, risk factors)	birthDate, gender, extension (race/ethnicity)
Condition	Risk factors modifying screening criteria	code, clinicalStatus, onsetDateTime
Observation	Screening results (labs, vital signs)	code, valueQuantity, effectiveDateTime, status
Procedure	Completed screenings (colonoscopy, mammogram)	code, performedDateTime, status
Immunization	Vaccination history	vaccineCode, occurrenceDateTime, status
DiagnosticReport	Imaging results (mammogram, LDCT, DEXA)	code, effectiveDateTime, conclusion
MedicationStatement	Medications affecting screening (e.g., statins)	medicationCodeableConcept, status
FamilyMemberHistory	Family risk factors (cancer, CVD)	condition, relationship

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract and calculate:

Age from birthDate
Sex from gender (administrative gender; biological sex may differ)
Smoking status: check Observation with LOINC 72166-2

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=72166-2&_sort=-date&_count=1"

Step 2: Retrieve Active Conditions (Risk Factors)

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Identify risk-modifying conditions:

Diabetes (SNOMED 44054006) -- affects statin, BP screening thresholds
HIV (SNOMED 86406008) -- affects STI, cancer screening frequency
Obesity (SNOMED 414916001) -- affects diabetes screening age
Immunocompromised states -- affects immunization recommendations
Family history of colorectal cancer -- earlier screening start
BRCA carrier status -- different breast cancer screening

Read the full file on GitHub · 390 lines

Files

What ships with it

2 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.

2mo ago First seen · 390 lines · 106 tokens per session scan A ad439becd086

Subscribe to this mod's changes

care-gap-identifier is a skill published in the GitHub repository langcare/langcare-mcp-fhir (71 stars, last pushed 6mo ago), licensed MIT. It adds 106 tokens to every session and 4,260 once invoked, about $0.0004 per session on Opus 5.5. 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 2026-08-30.

Scientific

care-gap-identifier next to 6 skills from other repositories
Mod	Type	Stars	Last push	Licence	Scan	Tokens	Works with
care-gap-identifierlangcare/langcare-mcp-fhir	Skill	71	6mo ago	MIT	A	106	Claude Code, Codex
instrument-data-to-allotropeanthropics/knowledge-work-plugins	Skill	35k	2d ago	Apache-2.0	A	123	Claude Code
exploratory-data-analysisK-Dense-AI/scientific-agent-skills	Skill	56k	4d ago	MIT	A	83	Claude Code
matlabK-Dense-AI/scientific-agent-skills	Skill	56k	4d ago	MIT	A	44	Claude Code
phylogeneticsK-Dense-AI/scientific-agent-skills	Skill	56k	4d ago	MIT	A	71	Claude Code, Codex
research-engineerdavila7/claude-code-templates	Skill	33k	yesterday	MIT	A	43	Claude Code, Codex
mapping-to-snomedmaziyarpanahi/openmed	Skill	5.8k	yesterday	Apache-2.0	A	205	Claude Code