Keloid follow up intake

Keloid Follow-Up Intake

Description

Use this skill to convert keloid follow-up notes, patient questionnaires, or visit transcripts into structured OpenScar follow-up summaries. It prepares clinician-reviewable fields for visit.csv, treatment.csv, and outcome.csv. It does not diagnose recurrence, determine treatment response, or recommend therapy.

When to Use

• A clinic needs a standardized keloid follow-up note.
• A researcher wants to convert follow-up records into OpenScar registry fields.
• A case has treatment exposure and needs structured symptom, adverse-event, and outcome documentation.
• A team wants to compare baseline and follow-up visits without losing uncertainty.

Do Not Use

• Do not decide whether a lesion is a keloid when the diagnosis is unclear.
• Do not determine recurrence without clinician review.
• Do not recommend injection, surgery, radiotherapy, laser, or other treatment.
• Do not ignore red flags such as infection, wound breakdown, ulceration, severe pain, bleeding, or rapid progression.
• Do not export identifiable data into research tables.

Required Inputs

• patient_id, lesion_id, and planned or existing visit_id.
• Baseline date offset and current visit_date_offset_days, not full calendar dates.
• Visit type: follow_up, treatment, complication, recurrence_check, or other.
• Patient-reported pain, itch, satisfaction, functional concern, and cosmetic concern if available.
• Since-last-visit treatments, adverse events, and any clinician observations.
• Available scar scale name and score, such as POSAS or VSS, if collected.

Workflow

1. Confirm the record is safe to structure:
   • Use de-identified IDs.
   • Remove direct identifiers and full dates from research outputs.
   • Escalate urgent symptoms before continuing with routine documentation.
2. Identify the follow-up context:
   • visit reason
   • days from baseline
   • prior treatment exposure
   • whether images were captured or planned
3. Extract patient-reported symptoms:
   • pain score from 0-10 when available
   • itch score from 0-10 when available
   • satisfaction score from 0-10 when available
   • function, clothing, movement, tenderness, bleeding, ulceration, or sleep impact
4. Extract clinician observations:
   • size or boundary changes if documented
   • height, firmness, erythema, pigmentation, tenderness, or contracture comments
   • uncertainty or missing measurements
5. Structure treatment exposure since the previous visit:
   • modality using OpenScar treatment_modality
   • treatment details in conservative text
   • combination session flag
   • adverse-event presence and details
6. Draft outcome fields only when the source supports them:
   • response_category
   • recurrence_status
   • recurrence_definition
   • functional_impact
   • cosmetic_impact
   • outcome_confidence
7. List missing fields and clinician-review questions.
8. Produce registry-ready row drafts plus a readable follow-up summary.

OpenScar Field Mapping

visit.csv

• visit_id
• patient_id
• lesion_id
• visit_date_offset_days
• visit_type
• clinician_assessment
• patient_reported_pain
• patient_reported_itch
• patient_satisfaction
• validated_scale_name
• validated_scale_score

treatment.csv

• treatment_id
• visit_id
• lesion_id
• treatment_modality
• treatment_detail
• combination_flag
• adverse_event_reported
• adverse_event_detail

outcome.csv

• outcome_id
• lesion_id
• assessment_visit_id
• follow_up_days_from_baseline
• response_category
• recurrence_status
• recurrence_definition
• functional_impact
• cosmetic_impact
• outcome_confidence

Outcome Label Guidance

Use conservative labels and preserve uncertainty:

• improved: source clearly reports reduced symptoms, size, elevation, erythema, or patient/clinician improvement.
• stable: source reports no meaningful change.
• worse: source reports progression without enough evidence to call recurrence.
• recurrence: clinician-reviewed recurrence is documented.
• partial_recurrence: limited regrowth is documented but not full recurrence.
• uncertain: source is ambiguous or conflicting.
• not_assessable: image, visit, or follow-up information is insufficient.

Use outcome_confidence as:

• high: clinician-reviewed statement, clear interval, and adequate documentation.
• moderate: likely interpretation, but one important element is missing.
• low: sparse, patient-only, image-limited, or conflicting information.

Output Format

Return:

• Follow-up summary
• Red flags and escalation status
• Registry row draft for visit.csv
• Registry row draft for treatment.csv, if treatment occurred
• Registry row draft for outcome.csv, if outcome can be assessed
• Missing fields and clinician-review questions
• Privacy and de-identification notes

Example Output Skeleton

Follow-up summary:
- Visit type: follow_up
- Days from baseline: 90
- Symptoms: pain 1/10, itch 3/10, satisfaction 7/10
- Clinician observation: reduced erythema and flattening documented

visit.csv draft:
- visit_id: v_pending_002
- patient_id: p_pending_001
- lesion_id: l_pending_001
- visit_date_offset_days: 90
- visit_type: follow_up
- clinician_assessment: reduced erythema and flattening; clinician review required
- patient_reported_pain: 1
- patient_reported_itch: 3
- patient_satisfaction: 7
- validated_scale_name: POSAS
- validated_scale_score: 24

outcome.csv draft:
- response_category: improved
- recurrence_status: no
- recurrence_definition: no increase beyond baseline lesion boundary at follow-up
- outcome_confidence: moderate

Clinician-review questions:
- Confirm whether recurrence definition is local protocol or clinician judgment.
- Confirm whether follow-up images are standardized.

Safety and Compliance

This skill supports documentation, research preparation, and clinician review. It does not diagnose, prescribe, determine recurrence, or replace licensed clinical judgment. Escalate urgent symptoms, suspected infection, wound breakdown, severe pain, rapid progression, bleeding, ulceration, or functional compromise to a qualified clinician.

Use de-identified IDs and date offsets for research exports. Do not include names, full dates, contact details, or identifiable image links in registry outputs.

Examples

Convert this day-90 keloid follow-up note into OpenScar visit, treatment, and outcome fields. The patient reports itch improved from 7 to 3, pain 1, satisfaction 7, and no adverse events after the prior steroid injection.

Summarize this recurrence-check visit and list what information is missing before the outcome can be labeled.

Integration

Works well with:

• scar-photo-standardization
• scar-treatment-response-review
• scar-registry-entry-builder
• scar-image-quality-review
• consent-form-review