Merge pull request 'feat(web): приложение пациента — двухэтапные опросы, результат скрининга, дневник по результату' (#79) from feat/rag-clinical-guidelines into dev

app/dialog/flows/core.py

@@ -70,7 +70,9 @@ async def onboarding_entry(ctx: Ctx, after: str | None = None) -> str:
     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")):
+    # Stage 1 is the same for everyone (ADR-012): it does not depend on modules, which it sets itself — an anonymous
+    # person has no profile at all before it.
+    if after is None and intake_enabled():
         return "intake.start"
     if after in modules:
         modules = modules[modules.index(after) + 1 :]

app/dialog/flows/intake.py

@@ -4,9 +4,13 @@ import math
 from dataclasses import asdict, replace
 from zoneinfo import ZoneInfo
 
+from app.core import interpretation
 from app.core.intake_questions import (
+    DIARY_KINDS,
+    Question,
     content,
     cssrs_answers,
+    cssrs_since_contact_question,
     diary_questions,
     group_answers,
     next_intake,
@@ -17,6 +21,7 @@ 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 import repo
 from app.db.intake import QuestionnaireRecord, QuestionnaireTask
 from app.dialog.contracts import Button, Event, Reply
 from app.dialog.crisis import crisis_open, open_crisis
@@ -28,21 +33,23 @@ def allowed(ctx):
     return ctx.data.get("consent") is True and ctx.data.get("adult") is True and intake_enabled()
 
 
+def side_effects_question():
+    """FIBSER-style tolerability question added to the full scales while a medication is active («Этап 2», p.3)."""
+    return Question("side_effects", texts()["side_effects"], ((1, "Да"), (0, "Нет")), "past_week")
+
+
 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 row.kind == "cssrs_since_contact":
+        return cssrs_since_contact_question(a)
+    if row.kind in DIARY_KINDS:
+        part = row.kind.removeprefix("diary_")
+        for q in diary_questions(part, row.details["modules"], day_index=row.details.get("day_index", 0)):
             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:
+            if q.id == "medication_reason" and a.get("medication") != "no":
                 continue
             return q
         return None
@@ -63,11 +70,7 @@ def next_question(row):
                     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 side_effects_question()
     return None
 
 
@@ -89,7 +92,7 @@ async def urgent(ctx, row=None, *, code="help_now", categories=None):
     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):
+    if row and (row.answers.get("dphq_9", 0) > 0 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})
@@ -132,7 +135,8 @@ 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":
+    # 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":
         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")
@@ -153,9 +157,6 @@ async def advance(ctx, row):
             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.
@@ -187,6 +188,8 @@ async def advance(ctx, row):
         extra = {"decision": asdict(result), "totals": service.summary(row)}
         if a.get("recent_trauma") == 1:
             extra["recent_trauma"] = True
+        extra["interpretation"] = interpretation.intake_interpretation(extra["totals"], a, result, policy)
+        await apply_modules(ctx, extra["interpretation"]["modules"])
         if result.primary_route != "self_help" or result.flags or result.parallel_routes or a.get("recent_trauma"):
             await service.alert(
                 ctx.session,
@@ -196,23 +199,29 @@ async def advance(ctx, row):
                 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)
+    elif row.kind == "cssrs_since_contact":
+        extra["totals"] = {"cssrs_recent": asdict(c)}
+        extra["interpretation"] = interpretation.cssrs_interpretation(c.risk)
+    elif row.kind in DIARY_KINDS:
+        # Morning and evening answers of one date form one diary day.
+        history: dict = {}
+        for r in await service.records(ctx.session, ctx.token):
+            if r.kind in DIARY_KINDS and r.status == "complete" and r.id != row.id:
+                history.setdefault(r.day, {}).update(r.answers)
+        history.setdefault(row.day, {}).update(a)
+        flags = diary_flags(history, row.day, medication_active=row.details.get("medication_active", False))
         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)
+            if flag in DIARY_SCALE_TASKS:
+                sid = DIARY_SCALE_TASKS[flag]
+                await service.queue_task(ctx.session, ctx.token, sid, row.id + ":" + sid, ctx.now)
+        extra["interpretation"] = interpretation.diary_interpretation(row.kind.removeprefix("diary_"), flags)
     else:
         extra["totals"] = service.summary(row)
+        runtime = load_runtime()
         if row.kind in ("phq9", "pcl5"):
             sid = row.kind
             total = extra["totals"][sid]["total"]
@@ -223,27 +232,37 @@ async def advance(ctx, row):
                 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,
-            )
+            earlier = [
+                r
+                for r in 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))
+            ]
+            prior = earlier[-1] if earlier else 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"),
+                    "retriage": change >= getattr(runtime, sid + "_retriage_delta"),
                 }
+            extra["interpretation"] = interpretation.scale_interpretation(
+                sid,
+                extra["totals"],
+                baseline=earlier[0].details["totals"][sid]["total"] if earlier else None,
+                previous=prior.details["totals"][sid]["total"] if prior else None,
+                policy=policy,
+                retriage_delta=getattr(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 row.kind == "rus_audit_s":
+            extra["interpretation"] = interpretation.scale_interpretation(
+                "rus_audit_s", extra["totals"], baseline=None, previous=None, policy=policy, retriage_delta=0
+            )
         if extra["totals"]["rus_audit"].get("zone") == 4:
             extra["parallel_routes"] = ["narcologist"]
         retriage = extra.get("delta", {}).get("retriage", False)
@@ -257,13 +276,48 @@ async def advance(ctx, row):
             params={"record_id": row.id, **extra},
         )
     await service.finish(ctx, row, "complete", extra=extra)
+    shown = interpretation.render(extra["interpretation"]) if extra.get("interpretation") else texts()["done"]
+    if row.kind == "cssrs_since_contact" and not await done_today(ctx, "diary_evening"):
+        # The risk questions open the evening diary; continue straight into it.
+        step = await start(ctx, "diary_evening")
+        step.replies.insert(0, Reply(text=shown, kind="info"))
+        return step
     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})
+    return Step(replies=[menu_reply(ctx, shown)], next_state="idle", data={"questionnaire_record": None})
+
+
+# Diary flags that bring a full scale forward («Этап 2», p.4).
+DIARY_SCALE_TASKS = {
+    "phq9_due_mood": "phq9",
+    "phq9_due_depression": "phq9",
+    "pcl5_due_ptsd": "pcl5",
+    "rus_audit_due_alcohol": "rus_audit_s",
+}
+
+
+async def apply_modules(ctx, modules):
+    """Stage 1 result → diary modules of stage 2. Without a doctor the screening defines them; a doctor's modules
+    (diagnosis from ЕМИАС) are kept and only extended."""
+    profile = await ctx.profile()
+    if profile is None:
+        await repo.upsert_profile(ctx.session, token=ctx.token, doctor_id="", modules=list(modules))
+        return
+    current = list(profile.modules or [])
+    merged = [*current, *(m for m in modules if m not in current)] if profile.doctor_id else list(modules)
+    await repo.upsert_profile(ctx.session, token=ctx.token, modules=merged)
+
+
+def local_day(ctx):
+    return ctx.now.astimezone(ZoneInfo(load_runtime().timezone)).date()
+
+
+async def done_today(ctx, kind):
+    day = local_day(ctx)
+    return any(
+        r.kind == kind and r.day == day and r.status == "complete"
+        for r in await service.records(ctx.session, ctx.token)
+    )
 
 
 async def start(ctx, kind="intake", task=None):
@@ -288,6 +342,8 @@ async def start(ctx, kind="intake", task=None):
         if task:
             return Step()
         return Step(replies=[Reply(text=texts()["review"], kind="info")])
+    # A manual start takes over the scheduled task of the same form, so the task does not stay outstanding.
+    task = task or await service.outstanding_task(ctx.session, ctx.token, kind)
     row = await service.create_record(ctx, kind, task=task)
     return await advance(ctx, row)
 
@@ -316,14 +372,28 @@ async def checkin(ctx, event):
     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")
+    return await next_diary(ctx)
+
+
+async def next_diary(ctx):
+    """The part of today's diary that is still open: morning first, then evening. The evening opens with the C-SSRS
+    «since last contact» when the profile is under suicide-risk monitoring («Этап 2», module of suicide risk)."""
+    day = local_day(ctx)
+    done = {r.kind for r in await service.records(ctx.session, ctx.token) if r.day == day and r.status == "complete"}
+    for kind in DIARY_KINDS:
+        if kind in done:
+            continue
+        profile = await ctx.profile()
+        if kind == "diary_evening" and profile and profile.enhanced_monitoring and "cssrs_since_contact" not in done:
+            risk_task = await service.queue_task(ctx.session, ctx.token, "cssrs_since_contact", f"cssrs:{day}", ctx.now)
+            return await start(ctx, "cssrs_since_contact", risk_task)
+        return await start(ctx, kind)
+    return Step(replies=[Reply(text=texts()["diary_done"], kind="info")])
+
+
+@trigger("button:diary:next")
+async def diary_button(ctx, event):
+    return await next_diary(ctx)
 
 
 @state("intake")
@@ -365,12 +435,16 @@ async def collect(ctx, event: Event):
     elif event.type == "text" and q.numeric:
         try:
             value = float(str(ctx.text).replace(",", "."))
-            valid = math.isfinite(value) and 0 <= value <= 24
+            valid = math.isfinite(value) and 0 <= value <= q.maximum
         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)])
+        hint = "invalid" if not q.numeric else ("numeric_portions" if q.id == "alcohol_portions" else "numeric")
+        return Step(replies=[Reply(text=texts()[hint]), question_reply(row, q)])
     service.save_answer(row, q, value, ctx.now)
+    if row.kind == "cssrs_since_contact" and q.id == "cssrs_q6_lifetime":
+        # Behaviour since the last contact is recent by definition (see cssrs_since_contact_question).
+        service.save_answer(row, replace(q, id="cssrs_q6_recent"), value, ctx.now, derived=True)
     return await advance(ctx, row)

app/dialog/flows/meds.py

@@ -47,6 +47,8 @@ from app.llm.med_qa import DOSE_QUESTION, fallback_text, med_qa
 
 QUESTION_STATE = "meds.question"
 SIDE_EFFECT_TEXT_STATE = "meds.side_effect_text"
+# A client sends this button when the person submits a free-text step without writing anything.
+NO_COMMENT = "text:skip"
 SIDE_EFFECT_CODES = ("nausea", "insomnia", "headache", "dizziness", "agitation", "other")
 SKIP_REASONS = ("forgot", "side_effects", "quit", "other")
 
@@ -379,7 +381,8 @@ def _side_effect_code(code: str) -> Any:
     async def handler(ctx: Ctx, event: Event, ref: str) -> Step:
         if code == "other":
             return Step(
-                replies=[Reply(text=load_meds_texts().side_effects.describe)],
+                # kind="question": the engine waits for free text here (clients show an input, optional).
+                replies=[Reply(text=load_meds_texts().side_effects.describe, kind="question")],
                 next_state=SIDE_EFFECT_TEXT_STATE,
                 data={"med_se_ref": ref},
             )
@@ -394,12 +397,15 @@ for _code in SIDE_EFFECT_CODES:
 
 @state(SIDE_EFFECT_TEXT_STATE)
 async def _side_effect_text(ctx: Ctx, event: Event) -> Step:
+    ref = ctx.data.get("med_se_ref")
+    if event.type == "button" and event.button == NO_COMMENT:
+        # The description is optional: «other» side effect without words.
+        return await _after_side_effects(ctx, ["other"], str(ref) if ref else None)
     if event.type != "text" or ctx.text is None:
         return await leave_to_idle(ctx, event, {"med_se_ref": None})
     facts = await ctx.gateway.extract_checkin(ctx.text)
     # Store only normalised codes, never the description itself (it stays in the scrubbed message log).
     codes = [str(c) for c in facts.side_effects] if facts is not None and facts.side_effects else ["other"]
-    ref = ctx.data.get("med_se_ref")
     return await _after_side_effects(ctx, codes, str(ref) if ref else None)
 
 
@@ -429,7 +435,7 @@ async def _menu_question(ctx: Ctx, event: Event) -> Step:
     t = load_meds_texts().question
     if await current_prescription(ctx) is None:
         return Step(replies=[menu_reply(ctx, t.no_prescription)])
-    return Step(replies=[Reply(text=t.prompt)], next_state=QUESTION_STATE)
+    return Step(replies=[Reply(text=t.prompt, kind="question")], next_state=QUESTION_STATE)
 
 
 async def answer_question(ctx: Ctx, rx: Rx | None) -> str: