Clinic Protocol Decision Support

Clinic Protocol Decision Support

What these tasks are

Every task in this family has the same shape:

1. A prompt names a target case id (e.g. CASE-<DOMAIN>-<NNN>) and a clinical domain.
2. An answer template (input/payloads/answer_template.json) defines the exact JSON schema: required top-level keys, enums, allowed values, list-ordering rules, null rules, and numeric precision. The template is the contract — every scored field is enumerated there.
3. A clinic runtime (FHIR-like) holds the patient record, encounters, observations, imaging, allergies, medications, problems, care-registry, SDOH, and protocol material. The runtime access (base URL, endpoints, any credentials) is listed separately for each run — consult that file for the mechanics of calling the runtime. Do not assume a prior run's URL or token.

The deliverable is one JSON object only — no markdown, no prose, no extra top-level keys.

Workflow

1. Read the template first. Before touching the runtime, read answer_template.json end-to-end. Note: required keys, enums + allowed values, which fields are string_or_null vs required, list-ordering rules, numeric precision, and any expected_constant / required_value fields (e.g. task_id, case_id are usually pinned). The template tells you exactly which evidence you must gather.
2. Pull the case record for the target case id from the runtime. A case record bundles: case, patient, findings (key/value clinical facts with source_id), observations, imaging, medications, allergies, problems, sdoh, and care_registry. This single record is usually sufficient; the global list endpoints are mostly distractors.
3. Pull the matching protocol. List protocols, then fetch the detail for the one whose scope matches the case type. The protocol body is authoritative — it carries the controlled LOINC/RxNorm codes, the authoritative_statuses (almost always ["final"]), escalation thresholds, dosing rules, follow-up timing, and return-precaution codes. When the template and your clinical instinct disagree, the protocol wins.
4. Reconcile data against rules (see references/decision_rules.md for per-domain patterns). Apply protocol thresholds literally; do not round, soften, or escalate beyond what the protocol states.
5. Build the JSON to the template. Use exact enum strings, exact identifier strings copied from the runtime, the prescribed numeric precision, and the prescribed list ordering.
6. Self-check against references/checklist.md before submitting.

Transferable rules (learned the hard way)

These apply across domains and are where points are lost:

Observations

• Final only. Protocol authoritative_statuses is ["final"]. Exclude preliminary, canceled, and entered-in-error observations from any "latest" or "matched" computation.
• Code identity matters. The protocol maps each concept to one controlled code. Serum potassium is code K ("in Serum or Plasma"). A whole-blood / point-of-care potassium (e.g. LOINC 6298-4, "in Blood") is a different code and must be excluded even if final. Sodium (NA), eGFR, HbA1c, phosphate, etc. are all distinct codes — never substitute.
• Patient identity matters. Distractor observations for other patients are planted inside a case. Always filter on the target patient_id.
• "Latest" = latest final target-code observation for the target patient, by effective_time.

Observation-window tasks

• Window from is inclusive, to is exclusive (the template states this). An observation exactly at to is out.
• matched_observation_ids = final + target code + target patient + inside window, sorted by effective_time ascending, then observation_id ascending.
• excluded_observation_ids = relevant distractors that fail to qualify by date, code, or status — these three reasons only. A wrong-patient observation is not listed in excluded; it is simply not relevant to this patient's review. (Including a wrong-patient id in excluded invalidates the whole set.) Sort excluded by effective_time ascending, then observation_id ascending.
• protocol_gate: pick from the enum based on the latest final value (normal → satisfies_recent_final_normal; low but not critical → repletion; critical/urgent → critical; none in window → no_final_lab_in_window).
• repeat_lab: when the gate is satisfies_recent_final_normal, no repeat is needed (recommended: false, scheduled_time: null). Reserve repeats for abnormal/urgent gates.

Numeric dose & timing conventions

• Follow the protocol's routine_dose_rule literally: e.g. mEq_per_0_1_mmol_l_below_target with round_to_nearest_mEq — compute the deficit from target_potassium_mmol_l, multiply, then round to the stated nearest value.
• "Next morning" follow-up lab = the next calendar day at 08:00 UTC (e.g. review 2026-02-10T10:15Z → 2026-02-11T08:00:00Z). Use LOINC / NDC codes straight from the protocol's controlled_codes.
• Numeric precision in the template is exact: one decimal place means 3.2 not 3.20; two decimals means 0.84. Blood pressure is a string "systolic/diastolic" (e.g. "152/88").

Escalation & disposition

• Escalation thresholds come from the protocol (e.g. respiratory ED escalation at SpO2 < 90, RR ≥ 30, SBP < 90, plus listed "other red flags"). Borderline values that don't cross a threshold do not escalate. SpO2 92–93% is a red flag but not an ED transfer; disposition stays outpatient_close_followup and stabilization_actions stays empty ([]) unless a threshold is crossed. Do not add supplemental_oxygen for borderline-but-not-hypoxic rooms.
• Match risk_level/risk_tier/disposition/imaging_recommendation/stabilization_actions to each other — they are scored for internal consistency. An over-aggressive stabilization will also drag down disposition and follow-up.

Allergies & medication plans

• Use active allergies only. Map allergens to the template's avoid_allergens enum (penicillin, sulfonamide, macrolide, tetracycline). "Sulfonamide antibiotics" → sulfonamide. Inactive allergies are ignored.
• Pick the antibiotic strategy the protocol supports for the allergy profile (e.g. CAP with penicillin + sulfa allergy → doxycycline_outpatient; avoid beta-lactam and sulfa classes). Set medication/dose/route/frequency/duration_days consistently with that strategy, or null where the template permits (e.g. supportive-care or ED-deferred strategies).

Safety checks

• Safety-check booleans reward not making false claims. Only assert a symptom is absent when the record explicitly documents it as absent (e.g. LOC "absent", vomiting 0 episodes, "no focal weakness"). For symptoms never assessed (e.g. photophobia not mentioned), do not list them as absent and keep the corresponding no_false_* check true.
• no_normal_cxr_claim / no_clear_lungs_claim: when imaging shows consolidation, never claim the CXR is normal or lungs are clear — set those checks true (you correctly avoid the false claim).

Lists that are "sets"

• Where the template says ordering is not meaningful, the evaluator normalizes lists as sets. But a set is scored strictly: one wrong element (extra or missing) can zero the whole field. Select exactly the codes the protocol/data support — no "just in case" extras.

evidence_ids

• Follow the per-task ordering rule. Head-injury: case id first, then clinical source ids. Potassium: "main observation, renal-function, and case evidence in descending relevance" (latest K obs, then renal/eGFR, then case id). Use real source_id / observation_id / imaging_id strings from the runtime.

Care-management routing

• Map each chart fact and disclosure to the specific priority-problem / referral code the protocol intends. Distinguish near-synonyms by case context: e.g. diastolic HF (HFpEF) with a volume-overload admission → hfpEF_post_volume_overload; a systolic-HF post-admission case → heart_failure_recent_admission. Don't select both for one case.
• Referrals are triggered by protocol rules: pharmacist (≥10 active meds, insulin, high-risk diuretic/electrolyte regimen), social_worker (≥2 moderate/severe SDOH domains among transportation/financial/food/housing), dialysis_care_coordination (ESRD on dialysis), transportation_benefits (transportation barrier). Do not add behavioral_health_monitoring for a mild PHQ-9 screen unless the protocol threshold is met.
• outreach_stance: permission_based_plain_language when the member is reluctant/refusing or when permission-based outreach is explicitly still required despite engagement.
• source_provenance.chart_facts = objective registry/lab/vital facts (risk_score, hba1c, phosphorus, blood_pressure, active_medication_count, recent_admission, dialysis_schedule, egfr only if an eGFR value exists). member_disclosure_needed = member-stated barriers and preferences (transportation_barrier, financial_food_barrier, dialysis_fatigue, care_goal_preference). Care-manager-noted facts (e.g. housing from a CM note) are not "member-disclosed."

References

• references/decision_rules.md — per-domain decision patterns (respiratory, head injury, potassium, care management, observation window).
• references/checklist.md — pre-submit verification checklist.
• references/data_model.md — shape of the runtime case record and protocol body so you know what to extract.