fix(clinical): red flags, one crisis rule, callback after a crisis, one table of numbers

Clinical review of the questionnaires (ADR-013):
- Red-flag block first in stage 1 (config/instruments/red_flags.yaml); any «Да» stops the
  questionnaire with an acute alert and the help screen of its category.
- One crisis rule: the crisis screen opens at a HIGH C-SSRS risk only; moderate stops and goes
  to a psychiatrist (24 h as a guide), low is a flag with the safety plan. PHQ-9 item 9 with a
  negative screener is a discrepancy flag; without a completed screener it asks the C-SSRS at once.
  config/questionnaire.yaml: cssrs_positive_policy graded (C01).
- Every crisis leaves a callback task for the doctor on duty (post_crisis_call, one per patient)
  and the app asks how the person is the next day, the safety plan one tap away.
- Routing: risk and flags first, scales second; PCL-5 >= 50 no longer means a priority
  appointment (pcl5_severe is moderate on the dashboard too).
- Crisis numbers live only in config/texts/crisis.yaml; texts and the agent prompt refer to them
  via {phone:<key>}. Fixes the children's helpline offered to adults by the chat agent.

Refs #92

Co-Authored-By: Claude Opus 5.5 <noreply@anthropic.com>

app/api/fixtures.py

@@ -16,6 +16,7 @@ from app.api.schemas import (
     PatientListItem,
     SeriesPoint,
 )
+from app.core.safety import fill_phones
 from app.integrations.base import Prescription
 
 TZ = ZoneInfo("Europe/Moscow")
@@ -262,7 +263,7 @@ def andrey_card() -> PatientCard:
             "Что помогает: прогулка с собакой, душ",
             "Люди и места: брат Олег, спортзал",
             "Кому звонить: жена, сослуживец Миша",
-            "Специалисты: д-р Смирнова, 8-800-2000-122, 112",
+            fill_phones("Специалисты: д-р Смирнова, {phone:helpline}, 112"),
             "Безопасная среда: ружьё хранится у брата",
         ],
         summary="За 13 дней: приверженность 12/13, эпизод намерения бросить на 5-й день (снят после звонка врача). "

app/core/instrument_catalog.py

@@ -13,7 +13,7 @@ from pydantic import BaseModel
 
 from app.config import get_settings
 from app.core.cssrs_content import load_cssrs_russian
-from app.core.intake_questions import DIARY_PARTS, content, diary_config, texts
+from app.core.intake_questions import DIARY_PARTS, content, diary_config, red_flags, texts
 from app.core.scales import load_scale
 
 Section = Literal["safety", "mood", "trauma", "alcohol", "about", "diary", "scale"]
@@ -92,6 +92,9 @@ def catalog() -> Catalog:
                 ),
             )
 
+    flags = red_flags()
+    add(FormInfo(id="red_flags", title="Вопросы о безопасности", section="safety"), [i["id"] for i in flags["items"]])
+
     cssrs = load_cssrs_russian()
     add(FormInfo(id="cssrs", title=cssrs.title, section="safety"), ["cssrs_" + i.id for i in cssrs.items])
 

app/core/intake_questions.py

@@ -53,11 +53,25 @@ def cssrs_answers(answers: dict) -> dict[str, int]:
     return {k.removeprefix("cssrs_"): v for k, v in answers.items() if k.startswith("cssrs_")}
 
 
+def red_flags() -> dict:
+    return yaml.safe_load((get_settings().config_dir / "instruments/red_flags.yaml").read_text(encoding="utf-8"))
+
+
+def red_flag_category(item_id: str) -> str | None:
+    return next((i["category"] for i in red_flags()["items"] if i["id"] == item_id), None)
+
+
 def next_intake(answers: dict, policy: IntakePolicy, sex: str | None) -> Question | None:
-    """Stage 1 in the fixed order of «Опросники для MVP»: PHQ-2, trauma filter → TSQ, RUS-AUDIT-S, C-SSRS screener,
-    then the context questions; stage 2 (rest of PHQ-9, PCL-5, full RUS-AUDIT) only where stage 1 is positive.
-    Items inside a scale keep the order of the source. The risk stop rules run after every answer (flows/intake.py),
-    so a positive answer interrupts the questionnaire wherever it comes."""
+    """Stage 1: the red-flag block first (config/instruments/red_flags.yaml), then the fixed order of «Опросники
+    для MVP»: PHQ-2, trauma filter → TSQ, RUS-AUDIT-S, C-SSRS screener, the context questions; stage 2 (rest of
+    PHQ-9, PCL-5, full RUS-AUDIT) only where stage 1 is positive. Items inside a scale keep the order of the source.
+    The risk stop rules run after every answer (flows/intake.py), so a positive answer interrupts the questionnaire
+    wherever it comes."""
+    flags = red_flags()
+    for n, item in enumerate(flags["items"]):
+        if item["id"] not in answers:
+            text = (flags["intro"] + "\n\n" if n == 0 else "") + item["text"]
+            return Question(item["id"], text, tuple((o["value"], o["label"]) for o in flags["options"]), "now")
     for item in ("phq9_1", "phq9_2"):
         if item not in answers:
             return scale_question("phq9", item)

app/core/interpretation.py

@@ -12,6 +12,7 @@ import yaml
 from app.config import get_settings
 from app.core.intake_questions import content
 from app.core.questionnaire import IntakeDecision, IntakePolicy
+from app.core.safety import fill_phones
 
 # Stage 1 finding → diary module of stage 2 (PTSD is the «veteran» module of the profile).
 FINDING_MODULE = {"depression_suspected": "depression", "ptsd_suspected": "veteran"}
@@ -23,7 +24,7 @@ PCL5_IMPROVED_BELOW = 28
 
 
 def texts() -> dict[str, Any]:
-    return yaml.safe_load((get_settings().config_dir / "texts/results.yaml").read_text(encoding="utf-8"))
+    return yaml.safe_load(fill_phones((get_settings().config_dir / "texts/results.yaml").read_text(encoding="utf-8")))
 
 
 def render(interpretation: dict[str, Any]) -> str:

app/core/questionnaire.py

@@ -50,7 +50,6 @@ class IntakePolicy(BaseModel):
     phq9_specialist_at: int = Field(ge=0, le=27, strict=True)
     phq9_priority_at: int = Field(ge=0, le=27, strict=True)
     pcl5_specialist_at: int = Field(ge=0, le=80, strict=True)
-    pcl5_priority_at: int = Field(ge=0, le=80, strict=True)
     pcl5_behavior_flag_at: int = Field(ge=0, le=4, strict=True)
 
     @model_validator(mode="after")
@@ -65,8 +64,6 @@ class IntakePolicy(BaseModel):
             raise ValueError("choose a total threshold OR a zone for alcohol expansion")
         if not self.phq9_psychologist_at < self.phq9_specialist_at < self.phq9_priority_at:
             raise ValueError("PHQ-9 thresholds must be ordered")
-        if self.pcl5_specialist_at >= self.pcl5_priority_at:
-            raise ValueError("PCL-5 thresholds must be ordered")
         return self
 
 
@@ -276,7 +273,9 @@ def evaluate_intake(
     if c.positive:
         flags.append("cssrs_positive")
     flags.extend(c.conflicts)
-    if item9_positive or c.risk_lower_bound == "high":
+    # One crisis rule (ADR-013): a high C-SSRS risk. Item 9 alone is a crisis only while the screener is not complete;
+    # with a negative / low screener it is the «discrepancy» flag of the routing table, not the crisis screen.
+    if c.risk_lower_bound == "high" or (item9_positive and not c.complete):
         return IntakeDecision(policy.version, "crisis", "crisis", (), tuple(flags), c.missing)
     if c.positive and policy.approval and policy.cssrs_positive_policy == "stop_any":
         return IntakeDecision(policy.version, "crisis", "crisis", (), tuple(flags), c.missing)
@@ -327,9 +326,11 @@ def evaluate_intake(
     # PHQ-2-negative does not invent a PHQ-9 total; it simply does not trigger expansion.
     phq_total = phq.total if phq.complete else 0
     pcl_total = pcl.total if pcl.complete else 0
+    # Risk and flags first, scales second (clinical review 2026-10-04). A high PCL-5 alone is not a reason for a
+    # priority appointment: it goes to the planned specialist route.
     if c.risk == "moderate":
         primary = "urgent_psychiatrist"
-    elif phq_total >= policy.phq9_priority_at or pcl_total >= policy.pcl5_priority_at:
+    elif phq_total >= policy.phq9_priority_at:
         primary = "priority_psychiatrist"
     elif phq_total >= policy.phq9_specialist_at or pcl_total >= policy.pcl5_specialist_at:
         primary = "psychiatrist_or_psychotherapist"

app/core/safety.py

@@ -395,6 +395,25 @@ def _crisis_cfg(path: Path = CRISIS_PATH) -> _CrisisCfg:
     return _CrisisCfg.model_validate(yaml.safe_load(path.read_text(encoding="utf-8")))
 
 
+_PHONE_REF = re.compile(r"\{phone:([a-z_]+)\}")
+
+
+def fill_phones(text: str, path: Path = CRISIS_PATH) -> str:
+    """Replace `{phone:<resource>}` with the number from the single table in config/texts/crisis.yaml.
+
+    Every patient text and prompt refers to the table instead of repeating a number, so a number is changed in one
+    place. An unknown resource fails loudly: a wrong number on the crisis screen must never pass silently.
+    """
+    resources = _crisis_cfg(path).resources
+
+    def number(m: re.Match[str]) -> str:
+        if m.group(1) not in resources:
+            raise ValueError(f"unknown crisis resource {m.group(1)!r}")
+        return resources[m.group(1)].phone
+
+    return _PHONE_REF.sub(number, text)
+
+
 def _render(body: str, resources: list[CrisisResource], doctor_notified: str, grounding: str) -> str:
     lines = [body.strip(), ""]
     for r in resources:

app/dialog/flows/intake.py

@@ -14,6 +14,7 @@ from app.core.intake_questions import (
     diary_questions,
     group_answers,
     next_intake,
+    red_flag_category,
     scale_question,
     texts,
 )
@@ -27,6 +28,7 @@ from app.dialog.contracts import Button, Event, Reply
 from app.dialog.crisis import crisis_open, open_crisis
 from app.dialog.fsm import Step, on_enter, state, trigger
 from app.services import questionnaire as service
+from app.services.followup import schedule_post_crisis_call
 
 
 def allowed(ctx):
@@ -105,6 +107,7 @@ async def urgent(ctx, row=None, *, code="help_now", categories=None):
         level=AlertLevel.ACUTE,
         params={"record_id": row.id if row else None, "flags": flags},
     )
+    await schedule_post_crisis_call(ctx.session, ctx.token, ctx.now, source="questionnaire:" + code)
     step = open_crisis(ctx, categories or [], source="questionnaire:" + code)
     step.data["questionnaire_record"] = None
     step.data["intake_review_required"] = True
@@ -113,6 +116,41 @@ async def urgent(ctx, row=None, *, code="help_now", categories=None):
     return step
 
 
+async def item9_discrepancy(ctx, row):
+    profile = await ctx.profile()
+    if profile:
+        profile.enhanced_monitoring = True
+    await service.alert(
+        ctx.session,
+        ctx.token,
+        row.id + ":phq9_cssrs_discrepancy",
+        "phq9_cssrs_discrepancy",
+        ctx.now,
+        level=AlertLevel.HIGH,
+        params={"record_id": row.id},
+    )
+    row.details = {**row.details, "item9_flagged": True}
+
+
+async def item9_assessment(ctx, row):
+    """Thoughts of death in PHQ-9 item 9 → the C-SSRS screener at once; the screener's level decides (graded)."""
+    await service.alert(
+        ctx.session,
+        ctx.token,
+        row.id + ":item9_assessment",
+        "phq9_item9_cssrs",
+        ctx.now,
+        level=AlertLevel.HIGH,
+        params={"record_id": row.id},
+    )
+    await service.finish(ctx, row, "complete", extra={"stop_reason": "phq9_item9_cssrs"})
+    profile = await ctx.profile()
+    if profile:
+        profile.enhanced_monitoring = True
+    task = await service.queue_task(ctx.session, ctx.token, "cssrs_since_contact", row.id + ":cssrs", ctx.now)
+    return await start(ctx, "cssrs_since_contact", task)
+
+
 async def manual_review(ctx, row, code):
     await service.finish(ctx, row, "review_required", extra={"stop_reason": code})
     await service.alert(
@@ -135,9 +173,24 @@ async def advance(ctx, row):
     a = row.answers
     c = score_cssrs_recent(cssrs_answers(a))
     policy = load_policy()
-    # PHQ-9 item 9 ≥1 — in the full scale or in the depression module of the diary — stops at once (stage 1 rule).
-    if a.get("phq9_9", 0) > 0 or a.get("dphq_9", 0) > 0 or c.risk_lower_bound == "high":
+    # Red flags (asked first): any «Да» stops the questionnaire with the help screen of its category.
+    for item_id, value in a.items():
+        if item_id.startswith("rf_") and value == 1:
+            category = red_flag_category(item_id)
+            return await urgent(ctx, row, code="red_flag_" + item_id[3:], categories=[category] if category else [])
+    # One crisis rule for the whole app (ADR-013): the crisis screen opens at a HIGH C-SSRS risk only. Moderate →
+    # stop + psychiatrist (about 24 h); low → flag, safety plan, continue.
+    if c.risk_lower_bound == "high":
         return await urgent(ctx, row, code="suicide_signal")
+    if a.get("dphq_9", 0) > 0 and row.kind in DIARY_KINDS:
+        # Diary depression module, item 9 ≥1 → the C-SSRS right away («Этап 2»); its risk level decides.
+        return await item9_assessment(ctx, row)
+    if a.get("phq9_9", 0) > 0 and not c.complete:
+        # Item 9 without a completed screener (only in a scheduled PHQ-9): assess the risk right away.
+        return await item9_assessment(ctx, row)
+    if a.get("phq9_9", 0) > 0 and not row.details.get("item9_flagged"):
+        # Item 9 ≥1 with a negative / low C-SSRS = discrepancy (routing table): flag to the doctor, safety plan.
+        await item9_discrepancy(ctx, row)
     if c.positive and policy.cssrs_positive_policy == "stop_any":
         return await urgent(ctx, row, code="cssrs_positive")
     if c.conflicts:
@@ -165,7 +218,7 @@ async def advance(ctx, row):
         return await manual_review(ctx, row, "answer_conflict")
     if q:
         replies = [question_reply(row, q)]
-        if c.complete and c.risk == "low" and not row.details.get("plan_shown"):
+        if ((c.complete and c.risk == "low") or row.details.get("item9_flagged")) and not row.details.get("plan_shown"):
             from app.dialog.actions import safety_plan_reply
 
             replies.insert(0, await safety_plan_reply(ctx))
@@ -225,11 +278,12 @@ async def advance(ctx, row):
         if row.kind in ("phq9", "pcl5"):
             sid = row.kind
             total = extra["totals"][sid]["total"]
-            priority = getattr(policy, sid + "_priority_at")
+            # Only PHQ-9 has a priority threshold; PCL-5 alone never makes an appointment a priority.
+            priority = getattr(policy, sid + "_priority_at", None)
             specialist = getattr(policy, sid + "_specialist_at")
             extra["route"] = (
                 "priority_psychiatrist"
-                if total >= priority
+                if priority is not None and total >= priority
                 else ("psychiatrist_or_psychotherapist" if total >= specialist else "review_with_treating_clinician")
             )
             earlier = [
@@ -284,7 +338,13 @@ async def advance(ctx, row):
         return step
     from app.dialog.flows.core import menu_reply
 
-    return Step(replies=[menu_reply(ctx, shown)], next_state="idle", data={"questionnaire_record": None})
+    replies = [menu_reply(ctx, shown)]
+    if ((c.complete and c.risk == "low") or row.details.get("item9_flagged")) and not row.details.get("plan_shown"):
+        # The safety plan is never skipped because the risk signal came with the last question.
+        from app.dialog.actions import safety_plan_reply
+
+        replies.insert(0, await safety_plan_reply(ctx))
+    return Step(replies=replies, next_state="idle", data={"questionnaire_record": None})
 
 
 # Diary flags that bring a full scale forward («Этап 2», p.4).

app/dialog/texts.py

@@ -7,6 +7,7 @@ import yaml
 from pydantic import BaseModel, ConfigDict, Field
 
 from app.config import get_settings
+from app.core.safety import fill_phones
 
 
 class _Strict(BaseModel):
@@ -91,6 +92,7 @@ class ReachOutTexts(_Strict):
     silence: str
     missed_doses: str
     default: str
+    after_crisis: str
 
 
 class VisitTexts(_Strict):
@@ -120,4 +122,4 @@ def dialog_texts_path() -> Path:
 @lru_cache
 def load_dialog_texts(path: Path | None = None) -> DialogTexts:
     path = path or dialog_texts_path()
-    return DialogTexts.model_validate(yaml.safe_load(path.read_text(encoding="utf-8")))
+    return DialogTexts.model_validate(yaml.safe_load(fill_phones(path.read_text(encoding="utf-8"))))

app/llm/agent/prompts.py

@@ -1,6 +1,8 @@
 """System prompt of the chat agent (Russian). Prohibitions follow SPEC §7; grounding: answer only from tools."""
 
-SYSTEM_PROMPT = """Ты — помощник пациента в сервисе сопровождения лечения между визитами к врачу. Пациент лечится у
+from app.core.safety import fill_phones
+
+_SYSTEM_PROMPT = """Ты — помощник пациента в сервисе сопровождения лечения между визитами к врачу. Пациент лечится у
 психиатра; ты отвечаешь на его вопросы о состоянии, лечении и лекарствах.
 
 Как работать:
@@ -32,4 +34,7 @@ SYSTEM_PROMPT = """Ты — помощник пациента в сервисе
 
 Стиль: по-русски, на «вы», спокойно и по-человечески, 3–6 коротких предложений, без markdown-заголовков.
 Если в вопросе есть признаки угрозы жизни — коротко скажи, что важно сразу позвонить 112 или на телефон
-доверия 8-800-2000-122, и что врач будет уведомлён."""
+доверия {phone:helpline}, и что врач будет уведомлён."""
+
+# Numbers come from the single table config/texts/crisis.yaml.
+SYSTEM_PROMPT = fill_phones(_SYSTEM_PROMPT)

app/scheduler/jobs.py

@@ -22,11 +22,13 @@ from app.db import repo
 from app.db.clinical import PatientProfile
 from app.db.intake import QuestionnaireTask
 from app.db.session import get_clinical_session
-from app.dialog.contracts import Event, Reply, get_engine
+from app.dialog.contracts import Button, Event, Reply, get_engine
+from app.dialog.texts import load_dialog_texts
 from app.integrations.base import integrations
 from app.scheduler import demo
 from app.services import monitoring
 from app.services import questionnaire as service
+from app.services.followup import next_day_check_due
 
 log = logging.getLogger(__name__)
 _worker = None
@@ -43,6 +45,15 @@ async def plan():
             state = await repo.get_dialog_state(session, profile.token)
             if not state or state.data.get("consent") is not True or state.data.get("adult") is not True:
                 continue
+            crisis = state.data.get("crisis")
+            if next_day_check_due(crisis, now):
+                # The day after a crisis the app asks how the person is, the safety plan one tap away.
+                texts = load_dialog_texts()
+                plan_button = Button(label=texts.safety_plan.title.rstrip(":"), data="safety_plan")
+                await integrations.outbox.push(
+                    profile.token, [Reply(text=texts.reach_out.after_crisis, buttons=[[plan_button]], kind="question")]
+                )
+                state.data = {**state.data, "crisis": {**crisis, "followup_sent": now.isoformat()}}
             rows = await service.records(session, profile.token)
             initial = next((r for r in reversed(rows) if r.kind == "intake" and r.status == "complete"), None)
             if initial is None:

app/services/followup.py

@@ -0,0 +1,43 @@
+"""Follow-up after a crisis (clinical review 2026-10-04: «план безопасности и звонок после кризиса — обязательно»).
+
+Every crisis — from the safety lexicon, a rule (PHQ-9 item 9, C-SSRS high) or the questionnaire (red flags, high
+risk) — leaves a task for the doctor on duty: call the patient back, about 24 hours as a guide. The task is an alert
+on the dashboard; «позвонили» is its acknowledgement (`repo.ack_alert`, audited). One open task per patient: a
+repeated crisis signal does not pile up callbacks. On the next day the app itself asks how the person is, with the
+safety plan at hand (`app/scheduler/jobs.py`).
+"""
+
+from datetime import datetime, timedelta
+
+from sqlalchemy.ext.asyncio import AsyncSession
+
+from app.core.types import AlertLevel
+from app.db import repo
+from app.db.clinical import Alert
+
+POST_CRISIS_CALL = "post_crisis_call"
+ON_DUTY = "on-duty"
+CALL_WITHIN = timedelta(hours=24)  # a guide, not a guarantee
+NEXT_DAY_CHECK_AFTER = timedelta(hours=20)
+
+
+async def schedule_post_crisis_call(session: AsyncSession, token: str, now: datetime, *, source: str) -> Alert | None:
+    if POST_CRISIS_CALL in await repo.open_alert_codes(session, token):
+        return None
+    return await repo.add_alert(
+        session,
+        token=token,
+        level=AlertLevel.HIGH,
+        code=POST_CRISIS_CALL,
+        reason="Перезвонить пациенту после кризиса — дежурный специалист, ориентир 24 ч. Отметка «позвонили» — "
+        "подтверждение этого сигнала.",
+        ts=now,
+        params={"due_at": (now + CALL_WITHIN).isoformat(), "assignee": ON_DUTY, "source": source},
+    )
+
+
+def next_day_check_due(crisis: dict | None, now: datetime) -> bool:
+    """The day after a crisis the app asks how the person is — once per crisis episode."""
+    if not crisis or not crisis.get("opened_at") or crisis.get("followup_sent"):
+        return False
+    return now - datetime.fromisoformat(crisis["opened_at"]) >= NEXT_DAY_CHECK_AFTER

app/services/monitoring.py

@@ -30,6 +30,7 @@ from app.db.audit import audit
 from app.db.session import get_clinical_session
 from app.integrations.base import integrations
 from app.services.contracts import register_monitoring
+from app.services.followup import schedule_post_crisis_call
 from app.services.snapshot import build_snapshot
 
 log = logging.getLogger(__name__)
@@ -93,6 +94,7 @@ class RuleMonitoring:
                         ts=now,
                     )
                     notify.append((ON_DUTY_DOCTOR, level, action.reason_ru))
+                    await schedule_post_crisis_call(s, token, now, source=f"rule:{action.code}")
             await refresh_status(s, token)
         log.info("monitoring token=%s actions=%s", token, [a.code for a in actions])
         for doctor_id, level, text in notify: