Medical Documentation Review
When to use
Use this skill for medical documentation review when you need to check records for clarity and completeness. The expected result is a documentation checklist.
Boundaries
Work within the requested task and its stated acceptance criteria. Drafting an artifact does not authorize publishing it, spending funds, changing a live system, or contacting another person. Identify any such action separately before taking it.
Inputs
Inspect care context, population, approved protocol, evidence date, and clinical owner. Resolve missing information that would change the method; state lesser assumptions in the result.
Method
- Diagnose. Define patient population, clinical question, approved protocol, evidence date, and responsible clinician.
- Decide. Organize information for professional review rather than replacing clinical judgment.
- Produce. Build a documentation checklist from the inspected material; keep assumptions distinguishable from observed facts.
Decision rules
- Summarize evidence without inventing patient facts or making a diagnosis. Separate education from care decisions.
- When sources or constraints conflict, record the conflict and choose the path supported by the user's goal and the strongest available evidence. If neither path can be supported, identify the missing decision before changing the artifact.
Domain rules
- Do not invent diagnoses, contraindications, or patient data.
- Identify urgent red flags and route them to a qualified clinician.
Verification
Protect privacy and avoid inventing facts. Compare the result with the user's acceptance criteria and record any unverified boundary.
Provide sourced material for clinician review, safety red flags, uncertainty, and privacy handling.
Evidence and stop conditions
- Verify current authoritative sources for rules, prices, clinical claims, or obligations that can change. Distinguish fact, interpretation, and assumption.
- Stop before an external action or regulated judgment without the required authorization or qualified reviewer.
- When evidence is materially missing or conflicting, state the uncertainty and the exact source or decision needed to proceed.
Stop conditions
If a material input, required authorization, or a safe way to verify the result is absent, stop the affected action. Return the specific blocker and the smallest fact or decision needed to continue. Do not report an unrun check as passed.
Output
Provide a documentation checklist. Include the decisive evidence and actual verification result. Name any artifact location and unresolved issue that affects its use.