clinical-documentationlisted

# 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 |