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Followup tracking

Skill aizech/clinical-skills/.bob/skills/followup-tracking

A collection of AI agent skills focused on medical imaging and healthcare workflows. Built for radiologists, healthcare IT professionals, and researchers who want AI coding agents to help with imaging workflows, clinical documentation, AI integration, and medical research. Works with Claude Code, Codex, Cursor, Windsurf, and many other agents.

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npx -y skills add aizech/clinical-skills --skill followup-tracking

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Track incidental findings, schedule follow-up imaging, and manage reminder workflows. Also use when the user mentions follow-up, incidental finding, reminder, or needs to track patients requiring follow-up imaging.

SKILL.md

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Follow-up Tracking

You are an expert in radiology follow-up tracking. Your role is to help manage incidental findings, schedule follow-up studies, and ensure patients receive appropriate surveillance.

Follow-up Categories

Incidental Findings

Common incidental findings requiring follow-up:

Finding	Typical Follow-up
Lung nodule <6mm	No routine follow-up
Lung nodule 6-8mm	CT at 6-12 months
Lung nodule >8mm	CT, consider PET, possible biopsy
Renal cyst	Usually no follow-up if simple
Renal mass >1cm	MRI or CT characterization
Adrenal nodule <1cm	No follow-up typically
Adrenal nodule >1cm	CT/MRI for characterization
Thyroid nodule	Based on TI-RADS

Surveillance Programs

Program	Population	Modality	Interval
Lung cancer screening	High-risk smokers	Low-dose CT	Annual
LI-RADS surveillance	Cirrhosis	MRI	Every 6 months
Breast screening	Women 40+	Mammography	Annual
Colonoscopy	Adults 45+	Colonoscopy	Every 10 years

Follow-up Protocols

Lung Nodule Follow-up

LUNG_NODULE_PROTOCOL = {
    "baseline_ct": {
        "indication": "New lung nodule detected",
        "protocol": "CT Chest with contrast (thin section)",
        "report_additional": "Nodule characteristics"
    },
    "followup_intervals": {
        "<4mm": {"action": "No routine follow-up", "category": "Lung-RADS 2"},
        "4-6mm": {"action": "CT at 12 months", "category": "Lung-RADS 2"},
        "6-8mm": {"action": "CT at 6-12 months", "category": "Lung-RADS 3"},
        "8mm solid": {"action": "CT at 3 months, PET, or biopsy", "category": "Lung-RADS 4"},
        "Ground glass": {
            "<6mm": {"action": "CT at 6-12 months"},
            ">=6mm": {"action": "CT at 6-12 months"},
            ">=20mm or growing": {"action": "Consider biopsy"}
        }
    }
}

Incidental Adrenal Nodule

ADRENAL_NODULE_PROTOCOL = {
    "<1cm": {"action": "No routine follow-up"},
    "1-2cm": {
        "action": "MRI or CT protocol for characterization",
        "indications": ["History of malignancy", "Imaging features concerning"]
    },
    ">2cm or concerning": {
        "action": "Dedicated adrenal CT/MRI, consider biopsy",
        "additional": "Chemical shift imaging"
    }
}

Tracking System Components

Patient Follow-up Registry Entry

FOLLOWUP_ENTRY = {
    "patient": {
        "name": "Patient Name",
        "mrn": "123456",
        "dob": "1980-01-15",
        "contact": {
            "phone": "555-123-4567",
            "email": "[email protected]"
        }
    },
    "finding": {
        "anatomy": "lung",
        "type": "nodule",
        "location": "right upper lobe",
        "size_mm": 8,
        "characteristics": "solid",
        "category": "Lung-RADS 4A"
    },
    "study": {
        "accession": "ACC123456",
        "date": "2026-03-15",
        "modality": "CT",
        "report": "Finding documented in full report"
    },
    "followup": {
        "type": "imaging",
        "study": "CT Chest",
        "due_date": "2026-09-15",  # 6 months
        "interval_months": 6,
        "status": "pending"
    },
    "communication": {
        "patient_notified": True,
        "provider_notified": True,
        "scheduled": False,
        "appointment_date": None
    }
}

Reminder Workflow

Patient Outreach

REMINDER_TYPES = {
    "initial": {
        "timing": "Within 48 hours of finding",
        "method": "Patient portal message + letter",
        "content": {
            "finding": "Explained in plain language",
            "why_followup": "Important for your health",
            "next_steps": "Instructions for scheduling",
            "contact": "Phone number for questions"
        }
    },
    "scheduling_reminder": {
        "timing": "1 week before due date",
        "method": "Phone call + portal",
        "content": {
            "study": "Reminder of scheduled scan",
            "preparation": "Prep instructions",
            "contact": "Reschedule if needed"
        }
    },
    "due_reminder": {
        "timing": "On due date",
        "method": "Phone call",
        "content": {
            "overdue": "Follow-up is due",
            "action": "Please schedule ASAP"
        }
    },
    "missed_appointment": {
        "timing": "After no-show",
        "method": "Phone call",
        "content": {
            "missed": "Apology for inconvenience",
            "importance": "Why follow-up matters",
            "reschedule": "Call to reschedule"
        }
    }
}

Letter Templates

Initial Follow-up Notification

Dear [Patient Name],

Your recent imaging study showed a finding that we recommend 
monitoring with follow-up imaging.

WHAT WAS FOUND:
[Plain language description of finding]

WHY IS FOLLOW-UP NEEDED?
[Explanation of why monitoring is important]

WHAT SHOULD YOU DO NEXT?
Please schedule a [type of scan] within [timeframe]. Your 
healthcare provider has been informed of this recommendation.

TO SCHEDULE:
Call: [Phone number]
Online: [Patient portal link]

QUESTIONS?
Contact your healthcare provider or call us at [number].

This finding does not require emergency care, but please do 
not delay scheduling the follow-up.

Sincerely,
[Radiology Department]

Overdue Follow-up Alert

SUBJECT: Follow-up Imaging Overdue - Action Required

Dear [Patient Name],

Our records show that your follow-up [type of scan] is now overdue.

FINDING TO MONITOR:
[Description]

ORIGINAL STUDY DATE: [Date]
FOLLOW-UP WAS DUE: [Date]

WHY THIS IS IMPORTANT:
Many findings like this remain stable over time, but it's 
important to check. This follow-up helps ensure your health.

WHAT TO DO:
Please call [number] today to schedule your follow-up scan. 
We can help find a convenient appointment time for you.

QUESTIONS?
Call [number] or message your healthcare provider through the 
patient portal.

Thank you for your attention to this matter.

[Radiology Care Team]

Quality Metrics

Follow-up Completion Rate

FOLLOWUP_METRICS = {
    "completion_rate": {
        "numerator": "Follow-up completed within recommended timeframe",
        "denominator": "All findings requiring follow-up",
        "target": ">80%"
    },
    "timeliness": {
        "numerator": "Follow-up completed within 30 days of due date",
        "denominator": "All completed follow-ups",
        "target": ">90%"
    },
    "patient_contact": {
        "numerator": "Patients contacted within 48 hours",
        "denominator": "All findings requiring follow-up",
        "target": "100%"
    }
}

Related Skills

care-gap-closure: For population health screening
patient-results-letter: For patient communication
guideline-integration: For evidence-based intervals
structured-reporting: For standardized findings documentation

Examples

Example 1: Create Follow-up for Lung Nodule

Set up follow-up tracking for a 7mm lung nodule

followup = {
    "patient": {"name": "John Smith", "mrn": "123456"},
    "finding": {
        "type": "lung_nodule",
        "size_mm": 7,
        "characteristics": "solid, smooth margins"
    },
    "study": {"date": "2026-03-01", "accession": "ACC001"},
    "followup": {
        "type": "CT Chest",
        "due_date": "2026-09-01",  # 6 months
        "interval": "6 months",
        "status": "pending",
        "provider_notified": True
    },
    "patient_contact": {
        "method": "letter + portal",
        "sent_date": "2026-03-03",
        "scheduled": False
    }
}

Example 2: Identify Missed Follow-ups

Find all patients with lung nodule follow-ups overdue by more than 30 days

query = {
    "finding_type": "lung_nodule",
    "size_range": "6-8mm",
    "status": "pending",
    "overdue_days": 30,
    "date_field": "followup_due_date",
    "comparison": "less_than",
    "reference_date": "today_minus_30_days"
}

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