What is langcare-care-gaps?

A patient care-gap checker that uses electronic health-record data to find overdue screenings, missing chronic-disease monitoring, and unmet quality measures.

Use it to review screenings, vaccinations, laboratory monitoring, and other preventive-care items, then prioritize what is current, due soon, or overdue.

It compares a patient’s records with preventive-care schedules and monitoring intervals so needed care is easier to spot.

langcare-care-gaps — 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-gaps

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-gaps/github.svg)](https://agentmods.dev/skills/langcare/langcare-mcp-fhir/care-gaps)

Your own site

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

Per session 62 Skills are progressive disclosure: only the name and description are preloaded; the body loads when the skill is used.

When invoked 714 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	$0.00062	$0.00714
Opus 5.5	$0.00025	$0.00286
Sonnet 5.5	$0.00012	$0.00143
Haiku 4.5	$0.00006	$0.00071

Measured 2mo ago against content hash 1c7c30207c9a, method: parsed. Prices are Anthropic first-party input rates as of 2026-10-07, from the pricing page.

Security

Grade A, and why

langcare-care-gaps 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.

cma/skills/care-coordination/care-gaps/SKILL.md · 64 lines

How it starts

The opening of the file, as written. The whole thing — 64 lines — stays where its author put it; the contents beside it link to each section on GitHub.

Care Gap Identifier

When to Use This Skill

Use when a clinician needs to identify overdue preventive screenings, missing chronic disease monitoring labs, and unmet quality measure criteria for an individual patient.

Clinical Workflow

Use fhir_read to retrieve Patient demographics (age, gender for screening eligibility)
Use fhir_search to pull active Condition resources for chronic disease monitoring requirements
Use fhir_search to pull Observation resources (labs, screenings) to check completion dates
Use fhir_search to pull Procedure and DiagnosticReport resources for cancer screenings (mammogram, colonoscopy, Pap)
Use fhir_search to pull Immunization resources for vaccination status
Apply USPSTF/ACS/ACIP screening schedules based on age, gender, and risk factors (see references/uspstf-recommendations.md)
For each applicable screening/monitoring item: determine if it was completed within the required interval; flag as current, due soon, or overdue
Present prioritized list of care gaps with recommended actions

FHIR Resources

Patient -- Age, gender for screening eligibility
Condition -- Chronic diseases requiring monitoring (DM, HTN, CKD)
Observation -- Lab results, screening scores (PHQ-9, AUDIT-C)
Procedure -- Screening procedures (colonoscopy, mammogram)
DiagnosticReport -- Screening results
Immunization -- Vaccination history

FHIR Query Examples

Pull Recent Screenings

fhir_search(resourceType="Procedure", queryParams="patient=[patient-id]&date=ge[3-years-ago]&_sort=-date")

Check Mammogram Status

fhir_search(resourceType="DiagnosticReport", queryParams="patient=[patient-id]&code=24606-6&date=ge[27-months-ago]")

Clinical Guidelines

USPSTF A and B grade recommendations
ACS cancer screening guidelines
ACIP immunization schedule
ADA diabetes monitoring standards
ACC/AHA lipid and BP monitoring guidelines

Interpretation Guide

Categorize gaps as: Overdue (past recommended interval), Due Now (within recommended window), Upcoming (due within 3 months)
Prioritize by clinical impact: cancer screenings, chronic disease monitoring, immunizations, general wellness
For each gap: state the screening/test, when it was last performed (or never), the recommended interval, and specific ordering action
Include age-specific screening eligibility cutoffs (e.g., colonoscopy 45-75, mammogram 50-74, lung cancer screening 50-80 with 20+ pack-year history)

Read the full file on GitHub · 64 lines

Files

What ships with it

1 file 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.

references/uspstf-recommendations.md 4.3 KB

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 · 64 lines · 62 tokens per session scan A 1c7c30207c9a

Subscribe to this mod's changes

langcare-care-gaps is a skill published in the GitHub repository langcare/langcare-mcp-fhir (71 stars, last pushed 6mo ago), licensed MIT. It adds 62 tokens to every session and 714 once invoked, about $0.0002 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.

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