Merge pull request 'feat(questionnaire): revised intake, diaries and follow-up monitoring' (#53) from feat/52-questionnaire into dev

Reviewed-on: #53

app/dialog/flows/core.py

@@ -42,6 +42,20 @@ def menu_reply(ctx: Ctx, text: str | None = None) -> Reply:
         [Button(label=b.contact_doctor, data="menu:contact_doctor")],
         [Button(label=b.revoke, data="consent:revoke")],
     ]
+    from app.core.intake_questions import texts
+    from app.core.intake_runtime import intake_enabled
+
+    if intake_enabled():
+        buttons.insert(0, [Button(label=texts()["help"], data="intake:help")])
+        buttons.insert(
+            0,
+            [
+                Button(
+                    label=texts()["resume"] if ctx.data.get("questionnaire_record") else texts()["start"],
+                    data="intake:resume" if ctx.data.get("questionnaire_record") else "intake:start",
+                )
+            ],
+        )
     return Reply(text=text or ctx.texts.idle.menu_prompt, buttons=buttons)
 
 
@@ -53,6 +67,10 @@ async def onboarding_entry(ctx: Ctx, after: str | None = None) -> str:
     profile (after `after`, if given) that has such a state registered; `"idle"` when none is left."""
     profile = await ctx.profile()
     modules = list(profile.modules) if profile is not None and profile.modules else []
+    from app.core.intake_runtime import intake_enabled
+
+    if after is None and intake_enabled() and any(m in modules for m in ("veteran", "depression")):
+        return "intake.start"
     if after in modules:
         modules = modules[modules.index(after) + 1 :]
     for module in modules:
@@ -275,6 +293,8 @@ async def _reach_out(ctx: Ctx, event: Event) -> Step:
 
 def close_crisis(ctx: Ctx) -> Step:
     """Doctor acknowledged the crisis: clear the flag; a C-SSRS still running returns to idle afterwards."""
+    if not (ctx.data.get("crisis") or {}).get("open") and ctx.state != "crisis":
+        return Step()
     crisis = {**(ctx.data.get("crisis") or {}), "open": False, "closed_at": ctx.now.isoformat()}
     scales = {
         sid: {**s, "return_state": "idle"} if s.get("return_state") == "crisis" else s
@@ -311,7 +331,11 @@ async def revoke(ctx: Ctx) -> Step:
     """
     async with get_identity_session() as s:
         await identity_repo.revoke_consent(s, token=ctx.token, now=ctx.now)
+    from app.services.questionnaire import cancel_pending
+
+    await cancel_pending(ctx.session, ctx.token)
     data = {
+        "questionnaire_record": None,
         "consent": False,
         "revoked_at": ctx.now.isoformat(),
         "delete_requested": True,

app/dialog/flows/intake.py

@@ -0,0 +1,376 @@
+"""Versioned, resumable questionnaires. Disabled until the clinical release gate opens."""
+
+import math
+from dataclasses import asdict, replace
+from zoneinfo import ZoneInfo
+
+from app.core.intake_questions import (
+    content,
+    cssrs_answers,
+    diary_questions,
+    group_answers,
+    next_intake,
+    scale_question,
+    texts,
+)
+from app.core.intake_runtime import diary_flags, intake_enabled, load_runtime
+from app.core.questionnaire import alcohol_expansion, load_policy, score_alcohol, score_cssrs_recent
+from app.core.scales import load_scale
+from app.core.types import AlertLevel
+from app.db.intake import QuestionnaireRecord, QuestionnaireTask
+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
+
+
+def allowed(ctx):
+    return ctx.data.get("consent") is True and ctx.data.get("adult") is True and intake_enabled()
+
+
+def next_question(row):
+    a = row.answers
+    if row.kind == "intake":
+        return next_intake(a, load_policy(), row.details.get("sex"))
+    if row.kind == "diary":
+        for q in diary_questions(
+            row.details["modules"], suicide_monitoring=row.details["suicide_monitoring"], weekday=row.day.weekday()
+        ):
+            if q.id in a:
+                continue
+            if q.id == "medication_reason" and a.get("medication") not in ("partial", "none"):
+                continue
+            if q.id == "side_effects" and a.get("medication") == "not_prescribed":
+                continue
+            if q.id == "thought_intensity" and a.get("death_thoughts") != 1:
+                continue
+            return q
+        return None
+    if row.kind in ("phq9", "pcl5", "rus_audit_s"):
+        sid = row.kind
+        if sid == "rus_audit_s":
+            short = score_alcohol(
+                {k: a[k] for k in load_scale(sid).item_ids if k in a}, short=True, sex=row.details.get("sex")
+            )
+            if alcohol_expansion(short, load_policy()):
+                sid = "rus_audit"
+        for item in load_scale(sid).item_ids:
+            if item == "rus_audit_2" and a.get("rus_audit_1") == 0:
+                continue
+            if item not in a:
+                q = scale_question(sid, item)
+                if sid == "pcl5" and row.details["weekly_pcl"]:
+                    q = replace(q, text=q.text.replace("последний месяц", "последнюю неделю"), period="past_week")
+                return q
+        if row.details.get("medication_active") and "side_effects" not in a:
+            return next(
+                q
+                for q in diary_questions([], suicide_monitoring=False, weekday=row.day.weekday())
+                if q.id == "side_effects"
+            )
+    return None
+
+
+def question_reply(row, q):
+    t = texts()
+    # Nonce + item + option index rejects old/replayed callbacks without exposing raw answers.
+    prefix = f"iq:{row.id[:12]}:{q.id}:"
+    buttons = [[Button(label=label, data=prefix + str(i))] for i, (_, label) in enumerate(q.options)]
+    if q.optional:
+        buttons.append([Button(label=t["comment_skip"], data=prefix + "skip")])
+    buttons.extend([[Button(label=t["help"], data="intake:help")], [Button(label=t["pause"], data="intake:pause")]])
+    return Reply(text=q.text + "\n\n" + t["as_of"].format(day=row.day.isoformat()), buttons=buttons, kind="question")
+
+
+async def urgent(ctx, row=None, *, code="help_now", categories=None):
+    if crisis_open(ctx.data):
+        return open_crisis(ctx, categories or [], source="questionnaire:" + code)
+    profile = await ctx.profile()
+    if profile:
+        profile.enhanced_monitoring = True
+    flags = list(service.decision(row).flags) if row else []
+    if row and (row.answers.get("death_thoughts") == 1 or row.answers.get("phq9_9", 0) > 0):
+        flags.append("cssrs_since_contact_required")
+    if row:
+        await service.finish(ctx, row, "interrupted", extra={"stop_reason": code, "flags": flags})
+    await service.alert(
+        ctx.session,
+        ctx.token,
+        f"{row.id if row else ctx.now.isoformat()}:{code}",
+        code,
+        ctx.now,
+        level=AlertLevel.ACUTE,
+        params={"record_id": row.id if row else None, "flags": flags},
+    )
+    step = open_crisis(ctx, categories or [], source="questionnaire:" + code)
+    step.data["questionnaire_record"] = None
+    step.data["intake_review_required"] = True
+    for reply in step.replies:
+        reply.buttons.append([Button(label=ctx.texts.safety_plan.title.rstrip(":"), data="safety_plan")])
+    return step
+
+
+async def manual_review(ctx, row, code):
+    await service.finish(ctx, row, "review_required", extra={"stop_reason": code})
+    await service.alert(
+        ctx.session, ctx.token, f"{row.id}:{code}", code, ctx.now, level=AlertLevel.HIGH, params={"record_id": row.id}
+    )
+    return Step(
+        replies=[
+            Reply(
+                text=texts()["missing_followup"] if code == "cssrs_since_contact_required" else texts()["review"],
+                buttons=[[Button(label=texts()["help"], data="intake:help")]],
+                kind="info",
+            )
+        ],
+        next_state="idle",
+        data={"questionnaire_record": None, "intake_review_required": True},
+    )
+
+
+async def advance(ctx, row):
+    a = row.answers
+    c = score_cssrs_recent(cssrs_answers(a))
+    policy = load_policy()
+    if a.get("phq9_9", 0) > 0 or a.get("death_thoughts") == 1 or c.risk_lower_bound == "high":
+        return await urgent(ctx, row, code="suicide_signal")
+    if c.positive and policy.cssrs_positive_policy == "stop_any":
+        return await urgent(ctx, row, code="cssrs_positive")
+    if c.conflicts:
+        return await manual_review(ctx, row, "cssrs_conflict")
+    # Finish the risk questions before any routine question; a moderate result stops here.
+    if c.complete and c.risk == "moderate":
+        return await manual_review(ctx, row, "urgent_psychiatrist")
+    if c.complete and c.risk == "low":
+        profile = await ctx.profile()
+        if profile:
+            profile.enhanced_monitoring = True
+        await service.alert(
+            ctx.session,
+            ctx.token,
+            row.id + ":cssrs_low",
+            "cssrs_low_safety_plan",
+            ctx.now,
+            params={"record_id": row.id},
+        )
+    if row.kind == "cssrs_since_contact":
+        # Recent and Since Last Contact are different instruments. No silent substitution.
+        return await manual_review(ctx, row, "cssrs_since_contact_required")
+    try:
+        q = next_question(row)
+        # Validate preserved short answers against a newly answered full-form item 1.
+        score_alcohol(group_answers(a, "rus_audit"), short=False, sex=row.details.get("sex"))
+    except ValueError:
+        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"):
+            from app.dialog.actions import safety_plan_reply
+
+            replies.insert(0, await safety_plan_reply(ctx))
+            row.details = {**row.details, "plan_shown": True}
+        return Step(replies=replies, next_state="intake.collect", data={"questionnaire_record": row.id})
+    extra = {}
+    if a.get("side_effects") == 1:
+        await service.alert(
+            ctx.session,
+            ctx.token,
+            row.id + ":side_effects_review",
+            "side_effects_review",
+            ctx.now,
+            params={"record_id": row.id},
+        )
+    if row.kind == "intake":
+        result = service.decision(row)
+        if result.status != "ready":
+            return await manual_review(ctx, row, "intake_incomplete_review")
+        extra = {"decision": asdict(result), "totals": service.summary(row)}
+        if a.get("recent_trauma") == 1:
+            extra["recent_trauma"] = True
+        if result.primary_route != "self_help" or result.flags or result.parallel_routes or a.get("recent_trauma"):
+            await service.alert(
+                ctx.session,
+                ctx.token,
+                row.id + ":route",
+                "intake_route_review",
+                ctx.now,
+                params={"record_id": row.id, **extra},
+            )
+    elif row.kind == "diary":
+        history = {
+            r.day: r.answers
+            for r in await service.records(ctx.session, ctx.token)
+            if r.kind == "diary" and r.status == "complete"
+        }
+        history[row.day] = a
+        flags = diary_flags(history, row.day)
+        extra["flags"] = flags
+        for flag in flags:
+            await service.alert(
+                ctx.session, ctx.token, row.id + ":" + flag, flag, ctx.now, params={"record_id": row.id}
+            )
+            if flag == "phq9_due_mood":
+                await service.queue_task(ctx.session, ctx.token, "phq9", row.id + ":phq9", ctx.now)
+    else:
+        extra["totals"] = service.summary(row)
+        if row.kind in ("phq9", "pcl5"):
+            sid = row.kind
+            total = extra["totals"][sid]["total"]
+            priority = getattr(policy, sid + "_priority_at")
+            specialist = getattr(policy, sid + "_specialist_at")
+            extra["route"] = (
+                "priority_psychiatrist"
+                if total >= priority
+                else ("psychiatrist_or_psychotherapist" if total >= specialist else "review_with_treating_clinician")
+            )
+            prior = next(
+                (
+                    r
+                    for r in reversed(await service.records(ctx.session, ctx.token))
+                    if r.id != row.id
+                    and r.status == "complete"
+                    and r.version == row.version
+                    and r.details.get("totals", {}).get(sid, {}).get("complete")
+                    and (sid != "pcl5" or r.details.get("weekly_pcl", False) == row.details.get("weekly_pcl", False))
+                ),
+                None,
+            )
+            if prior:
+                change = total - prior.details["totals"][sid]["total"]
+                extra["delta"] = {
+                    "baseline_record": prior.id,
+                    "value": change,
+                    "retriage": change >= getattr(load_runtime(), sid + "_retriage_delta"),
+                }
+        if row.kind == "rus_audit_s" and not row.details.get("sex"):
+            return await manual_review(ctx, row, "alcohol_sex_unknown")
+        if extra["totals"]["rus_audit"].get("zone") == 4:
+            extra["parallel_routes"] = ["narcologist"]
+        retriage = extra.get("delta", {}).get("retriage", False)
+        await service.alert(
+            ctx.session,
+            ctx.token,
+            row.id + ":followup",
+            "followup_retriage_required" if retriage else "followup_review",
+            ctx.now,
+            level=AlertLevel.HIGH if retriage or extra.get("route") == "priority_psychiatrist" else AlertLevel.MODERATE,
+            params={"record_id": row.id, **extra},
+        )
+    await service.finish(ctx, row, "complete", extra=extra)
+    from app.dialog.flows.core import menu_reply
+
+    replies = [menu_reply(ctx, texts()["done"])]
+    alcohol_total = extra.get("totals", {}).get("rus_audit", {})
+    if alcohol_total.get("zone") in (2, 3):
+        replies.insert(0, Reply(text=texts()["alcohol_advice"], kind="info"))
+    return Step(replies=replies, next_state="idle", data={"questionnaire_record": None})
+
+
+async def start(ctx, kind="intake", task=None):
+    if not allowed(ctx) or crisis_open(ctx.data):
+        if task:
+            return Step()
+        return Step(replies=[Reply(text=texts()["unavailable"], kind="info")])
+    existing = await service.records(ctx.session, ctx.token)
+    active = next((r for r in reversed(existing) if r.status in ("active", "paused")), None)
+    if active:
+        if task and task.record_id != active.id:
+            return Step()
+        if (
+            active.policy_version != load_policy().version
+            or active.version != content()["version"]
+            or active.details.get("runtime_version") != load_runtime().version
+        ):
+            return await manual_review(ctx, active, "questionnaire_version_changed")
+        active.status = "active"
+        return await advance(ctx, active)
+    if ctx.data.get("intake_review_required") and kind != "cssrs_since_contact":
+        if task:
+            return Step()
+        return Step(replies=[Reply(text=texts()["review"], kind="info")])
+    row = await service.create_record(ctx, kind, task=task)
+    return await advance(ctx, row)
+
+
+@on_enter("intake.start")
+async def enter(ctx):
+    return await start(ctx)
+
+
+@trigger("button:intake:start")
+@trigger("button:intake:resume")
+async def start_button(ctx, event):
+    return await start(ctx)
+
+
+@trigger("button:menu:checkin", replace=True)
+@trigger("system:daily_checkin", replace=True)
+async def checkin(ctx, event):
+    if not intake_enabled():
+        return Step(replies=[Reply(text=ctx.texts.idle.stub_checkin)])
+    if event.params.get("questionnaire_task"):
+        task = await ctx.session.get(QuestionnaireTask, event.params["questionnaire_task"])
+        if task is None or task.token != ctx.token or task.status not in ("pending", "active"):
+            return Step()
+        return await start(ctx, task.kind, task)
+    existing = await service.records(ctx.session, ctx.token)
+    if not any(r.kind == "intake" and r.status == "complete" for r in existing):
+        return await start(ctx)
+    day = ctx.now.astimezone(ZoneInfo(load_runtime().timezone)).date()
+    if any(r.kind == "diary" and r.day == day and r.status == "complete" for r in existing):
+        return Step(replies=[Reply(text=texts()["done"], kind="info")])
+    risk_task = await service.queue_task(ctx.session, ctx.token, "cssrs_since_contact", f"cssrs:{day}", ctx.now)
+    if risk_task.status in ("pending", "active"):
+        await service.queue_task(ctx.session, ctx.token, "diary", f"diary:{day}", ctx.now)
+        return await start(ctx, "cssrs_since_contact", risk_task)
+    return await start(ctx, "diary")
+
+
+@state("intake")
+async def collect(ctx, event: Event):
+    if not allowed(ctx):
+        return Step(replies=[Reply(text=texts()["unavailable"], kind="info")], next_state="idle")
+    row = await ctx.session.get(QuestionnaireRecord, ctx.data.get("questionnaire_record", ""))
+    if row is None or row.token != ctx.token or row.status != "active":
+        return Step(next_state="idle")
+    if (
+        row.policy_version != load_policy().version
+        or row.version != content()["version"]
+        or row.details.get("runtime_version") != load_runtime().version
+    ):
+        return await manual_review(ctx, row, "questionnaire_version_changed")
+    if event.type == "system":
+        task_id = event.params.get("questionnaire_task")
+        if task_id and row.details.get("task_id") == task_id:
+            return await advance(ctx, row)
+        return Step()
+    if event.button == "intake:pause":
+        row.status = "paused"
+        return Step(
+            replies=[Reply(text=texts()["paused"], buttons=[[Button(label=texts()["resume"], data="intake:resume")]])],
+            next_state="idle",
+        )
+    q = next_question(row)
+    if q is None:
+        return await advance(ctx, row)
+    prefix = f"iq:{row.id[:12]}:{q.id}:"
+    value = None
+    valid = False
+    if event.type == "button" and (event.button or "").startswith(prefix):
+        index = event.button[len(prefix) :]
+        if index == "skip" and q.optional:
+            valid = True
+        elif index.isdigit() and int(index) < len(q.options):
+            value, valid = q.options[int(index)][0], True
+    elif event.type == "text" and q.numeric:
+        try:
+            value = float(str(ctx.text).replace(",", "."))
+            valid = math.isfinite(value) and 0 <= value <= 24
+        except ValueError:
+            pass
+    elif event.type == "text" and q.optional:
+        value, valid = str(ctx.text)[:2000], True
+    if not valid:
+        return Step(replies=[Reply(text=texts()["numeric" if q.numeric else "invalid"]), question_reply(row, q)])
+    service.save_answer(row, q, value, ctx.now)
+    return await advance(ctx, row)